As Medicare Advantage and other government-sponsored value-based plans grow in importance and reach, so does the role of risk adjustment for payers and their members, providers, vendors and other stakeholders.

Risk adjustment programs, now accounting for up to one-third of payer revenue, are on the front lines of securing adequate capitated payments to care for many millions of older adults, children, high-needs individuals and other members. Risk adjustment leaders also want to leverage their programs to pinpoint and pursue opportunities to improve care, costs and member experience.

But challenges with harnessing data are jeopardizing appropriate risk adjustment as well as innovation. These challenges are undercutting accuracy, compliance and effectiveness even as the federal government increases scrutiny, legal action and penalties based on possible coding and MA risk scoring issues.

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