How to Utilize Existing Data to Correct Risk Adjustment Inaccuracies
Recent Medicare Advantage Analysis
The risk adjustment system is failing within Medicare Advantage, according to a recent report from the Alliance of Community Health Plans (ACHP).
After the launch of Medicare Advantage, the federal government created a risk adjustment program in 2001. It fully rolled out the program by 2007. The initiative guaranteed health insurers a fixed per-member, per-month payment to cover seniors with higher health needs. Payments adjusted based on each member’s illness level. The goal was to prevent adverse selection and make sure insurers that cover sicker populations received fair compensation.
Unfortunately, as the program expanded, aggressive coding rather than high-quality care has commanded more funding, costing American taxpayers billions of dollars annually. ACHP proposed The framework that aims to simplify risk adjustment by focusing on demographics and a small set of substantiated health conditions, rather than thousands of potential diagnoses, to ensure Medicare payments reflect true patient costs.
While FRG supports this suggestion and looks forward to the long-overdue systematic improvements, we realize this transformation could take insurers years to implement. In response to this issue, FRG created the Revenue Audit and Monitoring Program (RAMP) to address risk adjustment accuracy and empower health plans through customized reports.
Proactive Risk-Adjusted Revenue Management
Reports and dashboards in RAMP highlight opportunities for payors and providers to restore historically documented chronic condition codes and capture missing diagnosis codes, ensuring revenue alignment in active payment years. RAMP pinpoints both retrospective and prospective risk adjustment factors. It searches for missing diagnoses and matching codes by analyzing CMS data, claims, and other records. The team uses a big-picture view to predict diagnoses that providers haven’t documented. Utilization data, measures-related care, and pharmacy records often reveal health issues that need coding. These insights help payors capture accurate risk-adjusted scores.
Our team built RAMP to help clients understand the core principles of risk adjustment. We analyze member-level data for each payment year and create accurate, accrual-compatible forecasts for revenue recapture. FRG delivers clear findings that help payors plan member outreach, support providers, and fix coding errors. We close coding gaps and align medical expense budgets so patients receive the care they need.
Learn More This Month at HLTH 2025
To learn more about FRG and how RAMP can set your organization on a path to achieving accurate risk adjustment and, most importantly, financial health, visit our booking page or call 888-466-1025 to secure a demo at HLTH 2025.