Risk Adjustment Process Components

Are you Optimized for Risk Adjustment Performance and Compliance?

Navigant can assist health plans and provider organizations in the proactive and reactive assessment of their diagnosis capture activities and the submission of those diagnosis to payer organizations including commercial payers, state Medicaid programs, and CMS. We offer a cross functional team of experts with the skill sets required for providers and health plans requiring risk adjustment services including medical record coding, evaluation of diagnosis codes capture and submission processes, payment reconciliation, data analytics, and economic and statistical analyses.

Error mitigation across every process is essential for full submission and compliance effectiveness.


  • Documentation of member diagnoses during face-to-face encounters
  • Coding of diagnoses
  • Predictive software implementation
  • EMR usage and EMR data integrity
  • Risk sharing agreements between physician and payer organizations
  • Path to risk contracting strategy
  • Clinically integrated networks and population health strategy

Health Plan

  • Collect diagnoses from FFS claims and capitated encounters
  • Pay risk share and path to risk bonuses
  • Support joint ventures / partnerships
  • Proactive physician training
  • Missing diagnoses predictive modeling
  • Submit diagnoses via CMS RAPS files
  • Reconcile RAPS returns
  • Create financial projections
  • Optimize processes for chart retrieval and diagnoses identification
  • Diagnoses correlation with DM, STARS, HEDIS programs
  • Fraud identification, mitigation, and investigations
  • Proactive network medical record reviews\


  • Track CMS diagnoses and risk adjustment submission expectations
  • Track diagnoses submission to CMS and confirm CMS receipt of data
  • Conduct RADV Audits
  • Prepare for provider and home health focused regulatory inquires and audits
  • Estimate and recoup funds to CMS when errors are identified
  • Capture, investigate, and self-disclose hotline complaints
  • Anticipate and prepare for OIG focused audits on risk adjustment
Download the Process Components List

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