Most Medicare Advantage plans still run risk adjustment the way they always have — as a specialized function, staffed and led by risk adjustment experts.
That specialization built deep expertise, but it also built blind spots. Leaders trained in actuarial science, informatics and enterprise operations tend to measure efficiency and think in systems, and they catch inefficiencies that a career risk adjustment team stops seeing.
The stakes have risen sharply: CMS has expanded RADV audits from roughly 60 Medicare Advantage plans annually to all eligible MA contracts, and a risk adjustment operation built for the annual scramble is exposed in a way it was not two years ago.
This session brings together leaders from inside and outside traditional risk adjustment to show what a more continuous, connected operation looks like, and how to build one.
Learning points:
- Why risk adjustment has traditionally been run by specialists — and the blind spots that creates
- How leaders from actuarial and informatics backgrounds spot inefficiencies specialists miss
- Practical ways to bring outside perspective into risk adjustment: reporting structure, oversight and borrowed frameworks like systems audits and cost-per-unit tracking
- The systems, data and technology a modern risk adjustment operation depends on