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How to Enhance Risk Adjustment Accuracy

Enhancing Risk Adjustment Accuracy: How Jiva’s Risk Adjustment Navigator Drives Financial Success and Quality Care

ZeOmega’s blog series on risk adjustment looks at where we’ve been, what we’re facing today, what’s on the horizon, and how to best prepare. Over the preceding blogs, our ZeOmega risk adjustment solution experts have provided a forecast of regulatory changes and guidance on ensuring risk payment accuracy in both business and clinical operations.

The topics we have covered in this series are:

  1. Brief overview and history of the Risk Adjustment (RA) program.
  2. The results of RA policy and how it’s led to gamification of chronic condition coding.
  3. The value of risk-adjusted data across your organization.
  4. How overpayments in risk adjustment threaten the Medicare Trust Fund solvency.
  5. Recent federal actions and the next steps to control overpayments.
  6. Strategy and platform pivots required to move forward successfully in risk adjustment.
  7. ZeOmega’s expert tips and how the Jiva Risk Adjustment Navigator meets the evolving RA

Healthcare leaders are well aware of the critical role risk adjustment plays in their organization's financial stability and ability to deliver top-tier patient care. Whether driving Medical Loss Ratio improvements (MLR) or crafting high-value, business intelligence-driven benefit packages for members, accurate risk adjustment data reconciliation has impacts on both topline revenue and quality of care. Navigating the complexities of reconciling Centers for Medicare &Medicaid Services (CMS) files can be daunting, but Jiva’s Risk Adjustment Navigator solution revolutionizes risk adjustment program management while maintaining regulatory compliance.  In this final blog, we provide expert tips and demonstrate how the Jiva Risk Adjustment Navigator meets evolving RA demands.

The Challenge of Risk Adjustment

As we have covered throughout this blog series, federally funded safety net programs like Medicaid and Medicare are facing bleak financial forecasts causing federal and state overseers to crack down on attempts to gamify risk adjustment. Meanwhile, most vendor point solutions rely on controversial chart review and suspecting practices to bolster Risk Adjustment Factor (RAF) scores and often fail to deliver the return on investment they initially promised.

These tactics, if not closely monitored and regularly checked for compliance, often make organizations vulnerable to audit penalties. As stewards of both health outcomes and program sustainability, healthcare leaders need solutions that allow them to improve risk score reliability and meet financial targets. To achieve this, risk score reconciliation should be based on source of truth data, network performance should be closely monitored, and care teams across the organization should collaborate on condition recapture.

The Solution: Jiva’s Risk Adjustment Navigator

Our answer lies in Jiva’s state-of-the-art risk adjustment solution, the Risk Adjustment Navigator (RAN). Jiva’s new brand of navigator solutions combine both analytics and workflow into a single, fully integrated, real-time component of the Jiva enterprise platform. This approach allows customers to measure performance, detect trends, and query their data to fine-tune workflows through flexible, user-defined configuration.

RAN is designed to streamline and optimize risk adjustment processes, resulting in remarkable benefits for customers:

1. Seamlessly Integrated Data

RAN’s automated data integration capabilities enable effortless reconciliation of information from CMS and various state sources. No longer will teams struggle with data silos or manual data entry.

2. Standardized Accuracy

By applying standardized methodologies, RAN ensures consistent risk adjustment calculations across all datasets. This harmonization substantially reduces discrepancies, guaranteeing accuracy in risk score reporting.

3. Proactive Error Detection

Advanced algorithms and machine learning algorithms are at work within the software. They actively flag potential errors and inconsistencies, empowering users to address issues before they impact financial performance.

4. Compliance Confidence

With the software's precise and automated reconciliation, rest assured that customers meet all regulatory requirements and deadlines. Compliance is no longer a source of concern; it becomes a natural part of operations.

5. Optimized Financial Planning

Accurate risk adjustment data significantly enhances financial planning and revenue forecasting. Customers gain a clear understanding of their resources, enabling them to make strategic decisions with confidence.

6. Operational Efficiency

By automating the reconciliation process, staff can focus their efforts on higher-value tasks and care coordination, improving overall operational efficiency.

7. Recapture Performance Optimization

Advanced analytics and recapture performance reporting enables transparency between providers and payers. By identifying recapture opportunities across the population and provider recapture performance, customers can manage incentive programs and gain risk score accuracy.

8. Risk Mitigation

RAN’s built-in reconciliation minimizes discrepancies and errors in risk adjustment, effectively mitigating potential financial and compliance risks.

9. Expert Support

ZeOmega’s team of clinicians and subject matter experts works alongside customer teams to identify the right configuration needs and best practices. These experts have firsthand experience managing risk adjustment programs and have walked in our customers’ shoes.


As we close our risk adjustment series, it is important to reiterate the role organizations play in safeguarding the stability of federally funded healthcare. Balancing a health plan's financial success while maintaining compliance and avoiding the gamification of risk adjustment programs requires a strategic and ethical approach.

Implementing a fully compliant risk adjustment reconciliation solution like RAN is a forward-thinking approach that not only enhances both accuracy and efficiency but allows customers to analyze program metrics to ensure alignment with financial goals. By embracing this technological advancement, customers secure a brighter financial future, achieve compliance excellence, and provide the highest standard of care to members.

Let us help seize this opportunity to revolutionize risk adjustment processes and lead the healthcare industry in accuracy and efficiency ensuring access to healthcare for the millions of beneficiaries of today and tomorrow.

Jiva Risk Adjustment Navigator demonstrations are available. Please contact us for more information.