Accurately Capture Risk: Risk Adjustment Market Intelligence

For MA Plans, MSSP and REACH ACOs, providers with MA exposure, and organizations that work with or enable those entities

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Accurately capturing the acuity of your patient population is a key driver of value-based care success.

For risk-bearing organizations, your budget to manage a population is highly dependent on the health status of your patients. Your population’s demographics and comorbidities drive revenue if your organization is in MSSP, ACO REACH or Medicare Advantage.

Risk score

Market Benchmarks to Ensure Risk Coding Accuracy

Risk adjustment documentation and coding initiatives often involve resource intensive chart reviews at the patient level to ensure appropriate and accurate diagnoses submission. Market benchmark data comparing your Hierarchical Condition Category (HCC) Risk Adjustment Factor (RAF) scores to your peers’ can help ensure your diagnoses are accurate and appropriate.

CareJourney’s benchmark data can help you:

  • Evaluate the consistency of HCC risk adjustment coding practices among your provider network
  • Compare risk adjustment coding practices to market averages and peers
  • Investigate missed opportunities to appropriately code high-risk members
  • Identify potential fraud and abuse to support a compliance program
  • Identify differences in coding practices compared to market benchmarks

The Transition to HCC Model v28

In the 2024 Medicare Advantage Rate Announcement, CMS finalized substantial changes to the CMS HCC Risk Adjustment Model, transitioning from Version 24 to Version 28. The ACO REACH and Medicare Shared Savings Program (MSSP) are following suit. MA Plans, MSSP and REACH ACOs, providers with MA exposure, and organizations that work with or enable those entities need to understand the specific impacts on their populations in order to appropriately plan for the year ahead.

CareJourney data can help you:

  • Understand v24→v28 normalized risk score impact for your population
  • Evaluate what high volume HCCs and diagnoses are driving your impact
  • Benchmark your impact against the market or competitors

Risk Score Caps

CMS ACO programs, including MSSP and REACH, both include a concept of a risk score cap which limits the risk score growth of an ACO’s population vs a fixed reference year. There are model specific nuances including regional risk score growth limits (MSSP) and removing limits on demographic risk score growth (REACH).

CareJourney data can help you:

  • Evaluate RAF growth rates to understand weighted growth in your region
  • Breakdown RAF growth rates by demographic growth and disease growth 
  • Understand how your organization’s risk score will be impacted by growth and caps