Health plan revenue is increasingly tied to the concept of risk adjustment. In practice, risk adjustment aligns payments received by health plans with the risk of the populations they manage. Although each market has its own unique version of risk adjustment, accurate payment rests largely on encounter documentation and substantiation of submitted coding within the medical record, regardless of model.

Health systems that understand the principles of risk adjustment and can consistently prove complete and accurate code capture and documentation enjoy a strategic advantage in negotiating with health plans. On the flip side, provider organizations need to understand the financial implications of ineffective documentation on the bottom line as coding gaps can translate to millions of dollars of lost revenue.

Challenges exist for health systems to develop solutions to address deficiencies across the care continuum (i.e., pre-encounter phase, at the point of care, time of billing). Traditional health plan measures to close gaps from these process deficiencies are limited.

A more clinically beneficial approach for health plans is to develop strategies for increasing members’ level of engagement with their provider, who can then completely and accurately document. A health system can also contribute to improved documentation by deploying strategies in which health plans are required to adapt their processes to the health system’s approach, not the other way around.

This brief further outlines several steps health systems can establish to optimize processes for risk adjustment across the care continuum. Health systems can further capitalize on the opportunities risk adjustment provides by reframing it as a shared partnership effort between plans and providers.

Additionally, these efforts can not only lead providers to improved revenue integrity, cost savings and enhanced quality but also help prepare for the next stage of value-based payment. Read more to understand how HealthScape can help realize the value of risk adjustment.



Following these strategies can enable providers to realize the benefits of improved revenue integrity, cost savings and enhanced quality, while also helping them prepare for the next stage of value-based payment. To learn more about how HealthScape can help you reach this potential, contact us today.