The Power of Three: A New Model for Quality and Risk Adjustment Provider Engagement

Experienced quality and risk adjustment experts help improve member outcomes

By Sam Diederich, Vice President of Strategy and Business Integration, Optum

When payers manage quality and risk adjustment for government-sponsored membership, it creates a significant burden for care providers. Consider the situation from the provider’s point of view. Each payer sends data and asks for information back. But they all use different systems and mediums to exchange that information. This creates confusion and becomes time consuming.

Optimal engagement results in:

  • Improved quality and risk adjustment performance for payers
  • Less administrative burden, more crucial information about patient conditions, and more time to spend with patients for providers
  • Comprehensive care for patients, and more time with their physician

A new operating model, the power of three:


Providers are under increased pressure to improve risk and quality performance. Payers can’t expect to improve their engagement without rethinking their approach.

Each part of this model working together empowers providers to maximize participation and improve risk and quality performance.

Part 1: The experienced field team

Optum has developed a highly experienced national field team that engages providers at the point of care to improve performance. These provider engagement experts work on behalf of multiple payers to focus on all of a payer’s provider groups, regardless of size. The team consists of:

  • Medical directors
  • Provider support experts
  • Practice management experts
  • Medicare specialists
  • Health care advocates
  • Coders/abstractors
  • Telephonic provider support staff

These experts work directly with care providers within their workflow. They identify members in need of preventive measures or complex condition management. This includes:

  • Identifying best methods for sharing gaps in care
  • Accessing EMRs to push and pull data
  • Training/coaching to influence provider behavior
  • Preparing assessments

Provider engagement experts work with provider groups to accommodate their workflow support needs based on their unique circumstances.

Payers have traditionally employed aspects of this three-part model. However, technology without human engagement to drive the use of the technology becomes unproductive. Likewise, a provider engagement team without the oversight and management to achieve outcomes reduces the effectiveness.

Combining all three creates a highly effective model that maximizes participation, engagement and performance.

In Part 2 of this series, we’ll share how technology enablement can empower providers to identify diseases early and manage complex conditions.

Learn more about the quality and risk adjustment provider operating model


About the Author:

Sam pic_Provider_blog

Sam Diederich has spent nearly 10 years’ in the health care industry developing innovative strategies for Payers in the areas of risk adjustment, utilization management, and government-sponsored quality of care programs. He’s currently responsible for leading the development and execution of the growth, partnerships and integration strategy for the Optum Risk Adjustment & Quality business. Sam is a graduate of the University of St. Thomas’ Opus College of Business, where he studied Financial Management & Economics.

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