Risk Adjustment

Background

We help unravel the complexities of risk adjustment including developing program strategies, running effective and compliant programs, and analyzing program performance.

Welcome to our cutting-edge Risk Adjustment Services! At CareOne Consulting, we understand the highly regulated - and audited - landscape of risk adjustment, and we're here to empower you with the best practices that lead to the most accurate and complete risk scores.

Our comprehensive risk adjustment services are designed to build an audit-ready wall around your program and create an efficient operational model that focuses every dollar you spend efficiently.

Key Ways Our Clients Utilize Us:

RADV Prep and Support - We have been through them...many times. You want someone with the battle scars to know the process inside and out. Do NOT wait until you have been selected for a RADV. The process and subsequent fire drills can be minimized if you act timely and have experts on your side.
Operational Excellence - Our team have built and led programs at some of the largest health plans and vendors across the country. This kind of experience is invaluable to helping you spend each operational dollar wisely.
Program Evaluations - We have led and executed each part of the risk adjustment engine from analytics to submissions and everything in between. Let us perform a 360 of your program and provide recommendations on strengths, vulnerabilities, and deficiencies.
Submissions Support - Are you worried your submissions have a leak somewhere? Just like your own health, a great submissions team performs regular check-ups to find leaks and faulty processes. We know all the places to evaluate.
Analytics Review - Analytics drive your program from member segmentation to post-visit review and executive reporting. No analytics program is perfect and all analytics need continuous improvement initiatives. Our consultants have built, rehabbed, and refined analytics programs and products for vendors and plans across the country.

Join the list of health plans, provider groups, ACOs, and MSOs that have already experienced the positive impact of our risk adjustment services. Let us be your strategic partner in navigating the complexities of healthcare, safe-guarding revenue, and delivering exceptional operational performance.

Related Insights

5/1/24

CVS Made a Big Bet on Medicare. It’s Looking Risky

The healthcare giant cut its guidance for 2024 yet again

4/11/24

Medicare leaders discuss accountable care growth as part of NAACOS conference

Collaboration across CMS centers and with ACO participants is key.

4/1/24

CMS finalizes Medicare Advantage, Part D payment changes for CY 2025

Few surprises or material changes from the advanced notice. Plans may see wildly different impacts based on their population and programs.

3/18/24

MedPAC report slammed by insurers and docs over Medicare Advantage and physician reimbursement

Health plans and providers alike are disgruntled with a new report to Congress released by the Medicare Payment Advisory Commission (MedPAC).

2/9/24

Medicare Advantage headwinds didn't prevent payers from turning a profit in 2023

Though a spike in utilization among seniors slammed payers last year, particularly in the fourth quarter, each of the six major national firms turned a profit in 2023.

2/1/24

Medicare Advantage RADV Final Rule

The rule implements changes to the Medicare Advantage RADV program, which CMS uses to recover improper risk adjustment payments made to Medicare Advantage plans.

1/31/24

CMS Releases Proposed Payment Updates for 2025 MA and Part D Programs

Payers up against slight decline in 2025 Medicare Advantage payments

1/25/24

Humana posts $541 million loss in Q4, blames high Medicare Advantage costs

Humana's stock dipped following the earnings report, prompting the organization to cut its earnings guidance for this year and next.

1/5/24

US managed care companies lagged behind other insurers, S&P 500 in 2023

Shares of US managed care carriers generally underperformed other types of insurers and the wider market in 2023

11/28/23

HHS Proposes Keeping Same Risk Adjustment Policies for 2025, With Some Exceptions

If finalized, these proposals will generally take effect on January 1, 2025, unless otherwise noted.

11/16/23

CMS releases standards and payment parameters for plans on the ACA marketplace

Changes would increase incentives to engage the American Indian and Alaska Native population, whose communities have been underserved.

11/13/23

CMS proposes new Medicare Advantage audit appeals process

CMS proposed MA organizations be able to request a medical record review determination appeal or payment error calculation appeal, but not both at the same time.

10/26/23

Former HealthSun exec accused of Medicare fraud resulting in $53 mln overpayment

Prosecutors said that, in order to carry out their scheme, Valle and unnamed co-conspirators obtained physicians' login credentials to add fake diagnoses to patients' electronic medical records.

10/16/23

How CMS’ 2024 Risk Adjustment Rules May Affect Palliative Care Companies

The impact on individual palliative care providers will largely be determined by the terms of their current agreements with MA plans and how they apportion risk between the payer and provider entities.

10/11/23

Humana Sues HHS Over Final Rule on RADV Audits of MAOs

There is a greater number of Medicare beneficiaries who are reported to have a given condition than are documented to have that condition, and using one standard for risk adjustment payments and another for RADV audits is not an actuarially sound methodology.

10/9/23

OIG: Aetna may have received more than $25 million in MA overpayments

Most of the selected diagnosis codes that Aetna submitted to CMS didn't comply with federal requirements, OIG says.

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