When it comes to risk adjustment, health plans approach the task of gathering and reporting accurate data to CMS in several ways, including:

  • Retrospective in-home visits
  • Retrospective chart reviews
  • Third-party vendors who mine data for improperly coded diagnoses
  • Claims auditing
  • Ongoing provider education

While these methods can be effective, they have one notable thing in common: none of them put the member first. That’s because health plans primarily consider risk adjustment to be a data/coding problem. They look to solve it after the member’s visit with their physician has already taken place.

The challenge with these efforts is that they can drain a plan’s financial resources and create a burden on internal teams. Retrospective in-home visits, for example, are costly. They require the member’s consent and still require the provider to follow-up after. Retrospective chart reviews can be a lengthy process with a high risk of error. Data mining and claims auditing are worthwhile, but they can only mine and audit the diagnoses that have been coded. Provider education is also worthwhile, but only affects the members who go in for their visit.

The bottom line is that these risk adjustment methods are only effective if the members who need to get coded have a face-to-face visit with a diagnosing physician.

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The Value of a Proactive, Member-First Approach

Annual Wellness Visits (AWVs) are a face-to-face visit with a diagnosing physician, making them a key opportunity to identify hierarchical condition categories (HCCs)—which help determine risk adjustment payments from CMS.

Did you know? Just 18.8% of eligible Medicare beneficiaries receive an AWV.

By starting with the member, and motivating them to complete their AWV while empowering them to have a more productive visit with their physician, health plans can make their other risk adjustment efforts more effective.