Risk adjustment software: Key concepts and top vendors

Posted: January 31, 2024

Risk adjustment is a critical process that involves providers, payers, and healthcare administrators in the value-based care landscape, and plays an irreplaceable role in ensuring equitable healthcare delivery and reimbursement.

Given the complexity of risk adjustment, healthcare teams need modern software solutions to manage patient data efficiently and calculate risk scores at scale. In this guide, we’ll shed light on frequently asked questions in addition to providing a list of the best software vendors on the market. Here is a quick overview:

Healthcare risk adjustment FAQs
What to look for in a risk adjustment software solution
Leading risk adjustment software vendors

Whether you are new to risk adjustment or ready to choose a vendor, this guide will show you how technology is revolutionizing healthcare risk management and optimizing patient outcomes and financial sustainability.

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Healthcare risk adjustment FAQs

Risk adjustment analytics provide a statistical method to predict a patient group’s likelihood of using healthcare services and the associated costs. The method equates a patient’s health status to a number, called a risk score, to predict healthcare costs.

Providers submit diagnosis codes on claims data that define a patient’s risk score. Payers then rely on accurate risk adjustment to build health insurance plans. This payer-provider collaboration is essential for maintaining cost and quality standards across individual patient groups. In turn, effective collaboration ensures that patients receive appropriate compensation while supporting the equitable and efficient distribution of healthcare services.

Risk adjustment software is a specialized tool used to analyze patient data and perform risk score calculations.

In the past, traditional healthcare systems relied on paper-based workflows to finalize quality programs. This forced health plan quality and risk teams into a cycle of “chart-chasing” to capture evidence and verify risk and quality data, yielding decreased efficiency, underwhelming performance, and stifled communication.

Cloud-based and integrated risk adjustment software acts as the solution to this problem by reinventing the paper-based workflow and reporting structure. The software enables providers to identify and document suspected diagnoses at the point of care. Furthermore, networks can increase transparency and close risk gaps. This can lead to higher reimbursement and reinvestment into better patient care.

Fully functional risk adjustment software leverages several features to provide cross-network, effective care. Here’s an overview of each:

Risk scoring algorithms analyze a variety of patient data such as medical history, diagnoses, and treatments to calculate a risk score that indicates a patient’s likelihood of requiring significant healthcare resources, supporting accurate reimbursement.
Predictive analytics leverage statistical techniques and machine learning models to predict future health events and outcomes based on collected historical data. It is often used to identify high-risk patients and support proactive planning measures.
Reporting tools and dashboards present data in a digestible format. Providers use shareable reports for an in-depth view of patient populations, healthcare utilization, and more. The visualization of these tools makes it simple for teams to track these metrics over time to measure their program’s effectiveness.
Patient stratification categorizes patients based on their risk scores for targeted interventions. Providers rely on patient stratification to tailor their approach to different patient groups and divide their time and resources appropriately.
Real-time patient-provider collaboration facilitates immediate communication as the system updates so that both parties can access a timely view of risk and quality gap status and suggested interventions.

Armed with these modern features, care teams can enhance patient care and operational efficiency without worrying about administrative burdens.

When providers embrace risk adjustment software, it can greatly simplify their workflows. Watch this video for a closer look:

As described in the video, the risk adjustment process is threefold — suspect, engage, and assess:

Suspect: EHR-integrated software enables care teams to surface suspected risk gaps in patient care. These are areas where a patient’s risks are not fully accounted for in their records. The software uses integration and analysis to flag these risks based on treatment history, diagnosis codes, and clinical data.
Engage: The next step is to automate patient engagement with AI-powered care management tools such as appointment reminders and follow-up instructions based on individual patient profiles and risk assessments.
Assess: In the last phase, payers and providers use software to create workflows according to the identified risk gaps. This could include additional screenings, follow-up appointments, or interventions.

With the right software to support providers every step of the way, care teams can provide improved patient experiences and unlock increased savings from proactive resource allocation. This results in a win-win-win outcome for patients, payers, and providers.

What to look for in a risk adjustment software solution

To generate accurate cost predictions, providers must have access to a variety of data (inpatient, pharmacy, SDoH, etc.) at the point of care. This is where EHR-integrated risk adjustment software comes into play. When narrowing your software search, here are a few essential features to prioritize:

A list of what to look for in risk adjustment software solutions including comprehensive data integration, risk factor identification, risk scoring accuracy, reliable adjustment models, scalability and flexibility, and user-friendliness

Comprehensive data integration: The solution you choose should have high-powered integration capabilities so you can process data from multiple sources with confidence and pave the way for more accurate risk assessments.
Risk factor identification: To plan informed and targeted interventions, your providers need to rely on a system that easily pinpoints high-risk patients. Without this capability, your team won’t be able to sufficiently allocate resources and increase care efficiency.
Risk scoring accuracy: This feature is a cornerstone of risk assessment since inaccurate scoring can lead to inaccurate payment for services and directly affect financial and operational sustainability and patient care quality.
Reliable adjustment models: Look for a solution that offers a standardized approach for meaningful comparison across different patient groups, providers, and periods. That way, you can be confident in your benchmarking, performance assessment, and healthcare planning decisions.
Scalability and flexibility: As your organization evolves, your software should adapt too. Find one that easily keeps up with changing patient population trends, regulatory expectations, and increased operational demand.
User-friendliness: Healthcare providers need to be able to efficiently navigate your platform. A user-friendly interface is necessary for care teams to adopt the system into their existing workflows without extensive training.

Study vendor reputation and compare their services to your immediate and long-term needs. For more information, consider scheduling personalized demos to see the software in action. Collaborate with your key stakeholders throughout the decision-making process so that everyone is on the same page, from software selection to implementation.

Leading risk adjustment software vendors

Top pick: Arcadia

As a KLAS Featured IT Vendor, Arcadia simplifies risk coding and documentation to provide clear visibility across your entire network. Our comprehensive risk adjustment application library can help you unearth meaningful data points and drive healthier outcomes. Here’s an overview of each featured application:

Healthcare data model built by analysts for analysts to place quality, risk, financials, contracts, and clinical data into a simplified schema.
Analytics dashboards to empower clinical and operational care teams to create customizable workflows and extract insights from massive data volumes.
Healthcare reporting for providers simplifies meaningful report creation and distribution to executives and other stakeholders.
Point-of-care insights available within your existing EHR workflows that present actionable opportunities for providers to address risk gaps at the time of treatment.
Provider-payer collaboration with cloud-based, configurable workflows to accommodate real-world variation between payers, health systems, and state requirements.
Unified SDoH data that streamlines the population identification process to direct providers to groups in need of immediate care.

Additionally, our HCC Risk Suspecting App aggregates data from multiple sources (claims, EHR, APIs, SDoH) and then enriches it with a proprietary risk-suspecting engine. The app integrates payer and EHR data into a single data asset, enabling diagnosis suspecting from notes, labs, orders, and vitals. Get a closer look in the video below:

Advantasure

Advantasure provides comprehensive and balanced risk adjustment solutions to achieve complete and compliant risk score accuracy. Their specific services include:

Bid process input
Data-driven strategy development
Value and cost projection
Member risk adjustment gap identification
Provider performance education and reporting
Performance management reporting

Advantasure recommends bundling its risk adjustment program with administrative and care management solutions to experience comprehensive success.

Advantmed

Advantmed offers end-to-end risk adjustment solutions with 98% coding accuracy to provide accurate risk profiles for enhanced results. Here’s an overview of its risk adjustment services:

Advanced analytics
Medical record retrieval
Medical record coding
Claims and data validation
Health assessments

With Advantmed, providers can access understandable, actionable analytics that improve Risk Adjustment Factor (RAF) scores to close documentation gaps and utilize prevention and predictive modeling.

Apixio

Apixio is an AI-powered technology that increases risk adjustment accuracy and efficiency to decrease administrative time and cost. The platform’s risk adjustment coding and auditing solutions help teams scale chart review processes and capture complete pictures of patient population health. Apixio’s core risk adjustment services include:

Retrospective risk adjustment
Prospective and concurrent risk adjustment
AI-as-a-service for retrospective risk adjustment
AI-as-a-service for prospective risk adjustment

Equipped with these features, Apixio eases the coding workload and decreases the chart review process time without sacrificing coding accuracy.

Change Healthcare

Change Healthcare’s comprehensive risk adjustment platform, Risk View, helps healthcare insurers understand risk score trends and opportunities, optimize financial results, and identify targets for appropriate risk-adjusted reimbursement. Its risk adjustment solutions include:

Risk adjustment software and strategy tools
Targeted advanced risk analytics
Risk adjustment activity management
Standardized and customized reports and dashboards

Change Healthcare offers comprehensive reports to inform strategic planning based on end-of-year and end-of-project metrics. Models used AI, big data, and chart selection to assess and target appropriate members.

Cotiviti

Coviti’s risk adjustment solutions ensure compliant, accurate compensation for member risk burdens. The platform provides advanced tools to optimize risk-associated revenue while maintaining transparency at every stage of the process with the following services:

Suspect analytics
Medical record retrieval
Medical record coding

Cotiviti’s extensive risk adjustment experience and deep subject matter expertise can help organizations keep tabs on their programs to enable accurate reimbursement from accurate documentation.

Episource Clarity Platform

The Episource Clarity platform is an end-to-end solution for risk adjustment and quality initiatives built to deliver tangible outcomes for leading health plans and risk-bearing providers. The platform portal includes the following applications:

RAF analytics and suspecting tools
Data acquisition services
NLP-powered medical chart coding
Clinical support including provider engagement and pre-visit review
EDI data submission

Intending to “provide clarity at every stage,” the Episource Clarity Platform supports care teams by identifying areas of opportunity, assessing program performance, and providing comprehensive compliance review.

Pareto

Pareto’s risk adjustment solution, Pareto Hub, is a cloud-based data environment built by business experts that transforms and enriches raw, disparate data assets into business-ready analytics. The solution’s core capabilities include:

RADV mock audit and support
Program evaluation and strategy
Compliance risk assessments
Coding services
Medical coding compliance evaluations
In-home assessments
Virtual home visits
Advisory services

Pareto’s Data Management Platform enables data ingestion of all formats and types at scale with built-in governance mechanisms that maintain compliance and efficiency.

Risk Adjustment Software: Final thoughts

Accurate risk adjustment requires several moving parts to work simultaneously — data collection and analysis, standardization, predictive modeling, and continuous monitoring. A robust software solution can automate many of these processes resulting in enhanced collaboration, accurate reimbursement, and improved patient care.