Bridging Silos: How Quality and Risk Adjustment Teams Can Drive Shared Outcomes in Medicare Advantage
In the evolving Medicare Advantage landscape, plans are under unprecedented pressure to do more with less. They must demonstrate superior clinical outcomes, deliver exceptional member experiences, and maintain precise, compliant documentation all while navigating complex regulatory changes.
Yet, despite shared goals, Risk Adjustment and Quality Improvement teams often operate in parallel universes. This organizational separation creates missed opportunities to drive holistic performance.
It doesn’t have to be this way. Aligning these teams can unlock measurable improvements in Stars ratings, RAF scores, compliance, and member engagement. This article explores how to bridge the gap – grounded in technical detail, not vague platitudes.
Understanding the Divide
Before integration can happen, it’s essential to be clear-eyed about why silos exist.
- Different Objectives
- Risk Adjustment teamsfocus primarily on ensuring diagnoses are accurately documented and submitted to CMS to calculate risk scores. The goal: obtain appropriate revenue to care for high-acuity members.
- Quality Improvement teamstarget process and outcome measures,like medication adherence, preventive screenings, and chronic condition management,that drive Stars ratings and bonuses.
These priorities are interdependent but have traditionally been treated as separate lanes.
- Distinct Data and Processes
- Risk Adjustment relies heavily on retrospective data—historical encounter records and supplemental data (e.g., chart reviews).
- Quality programs often use prospective workflows, including real-time care gap alerts and member outreach.
- Even when data overlaps (e.g., evidence of a diabetic retinopathy screening), systems and teams don’t always communicate effectively.
- Cultural and Structural Barriers
- Different reporting hierarchies.
- Separate vendor relationships.
- Limited shared performance metrics.
The Business Case for Integration
When these teams remain siloed, health plans leave tangible value on the table:
- Inaccurate coding under-reflects member acuity, suppressing RAF scores and reducing reimbursement.
- Unclosed care gaps lower Stars ratings, costing bonus dollars and market competitiveness.
- Disjointed member outreach confuses patients, damaging satisfaction and engagement.
Conversely, integrated strategies create multiplicative returns:
Outcome Area | Impact of Integration |
Stars Ratings | Faster closure of care gaps with accurate documentation |
RAF Scores | More complete, timely capture of chronic conditions |
Compliance & Audit Readiness | Reduced discrepancies across risk and quality submissions |
Member Experience | Fewer redundant touches, clearer communications |
How Integration Actually Works
Let’s look under the hood at how leading plans are aligning Risk Adjustment and Quality in practice.
- Unified Data Aggregation and Normalization
The first critical step is creating a single source of truth. This requires:
- Data ingestion pipelinesthat consolidate:
- EMR data
- Claims
- Supplemental data from chart reviews
- Lab and pharmacy feeds
- Member outreach results
- Normalization logicto map diverse coding systems (ICD-10, CPT, HEDIS value sets) to unified member records.
- Data lineage trackingto ensure auditability—so each diagnosis or gap closure can be traced to its origin.
Many plans leverage a data lake architecture with layered access models—allowing teams to consume only the views they need without duplicating extracts.
- Integrated Suspect Condition Lists
Traditionally, Risk Adjustment teams build suspect lists (conditions likely to exist but undocumented) using predictive models or claims gaps.
Quality teams, meanwhile, generate care gap lists (e.g., overdue HbA1c tests, missing eye exams).
Leading organizations are:
- Merging suspect condition lists with care gap lists to produce unified member prioritization.
- For example, if a diabetic member lacks both a documented diabetic neuropathy diagnosis (impacting RAF) anda current A1c screening (impacting Stars), they are flagged for coordinated intervention.
This approach ensures every outreach touchpoint is clinically and financially optimized.
- Shared Workflows and Outreach Strategies
Consider how many times a member gets contacted separately by different teams:
- One call to verify a diagnosis.
- Another to schedule a preventive screening.
- A third about medication adherence.
Integrated workflows replace these redundancies with single, multi-purpose outreach scripts and scheduling. For example:
- Contact Center Integration:Unified call scripts that confirm diagnoses, schedule screenings, and offer health coaching.
- Member Portal Integration:Consolidated reminders and self-service scheduling.
- FieldCoordination: In-home assessments that both collect diagnostic data and close care gaps.
This approach not only improves efficiency but also reduces abrasion, improving CAHPS survey scores.
- Integrated Reporting and Performance Measurement
Once workflows are unified, measurement must follow. Plans are developing composite dashboards displaying:
- HCC coding closure rates by condition category.
- Care gap closure percentages by measure.
- Member-level views of risk and quality status.
- Financial impact models showing estimated RAF uplift and Stars bonuses.
These dashboards are often built in BI platforms such as Tableau or Power BI, with data sourced from an enterprise data warehouse.
How Annova Supports Integrated Risk and Quality
Annova Solutions provides:
- End-to-End Data Aggregation:Our platform ingests claims, EMR, and supplemental data, normalizing it into unified member profiles.
- AI-Driven Analytics:Predictive models that identify both coding gaps and care gaps.
- Integrated Outreach Enablement:Tools to manage and track multi-purpose member engagement.
- Audit-Ready Documentation:Clear data lineage and version-controlled records.
With Annova, plans can move from fragmented workflows to a cohesive, member-centered strategy.
Conclusion
As CMS expectations rise and competition intensifies, the plans that succeed will be those who tear down silos between Risk Adjustment and Quality.
The future isn’t just about getting diagnoses documented or care gaps closed—it’s about doing both together, in service of better outcomes and financial sustainability.
If you’d like to learn how Annova can help your organization build an integrated strategy, contact us or explore our solutions.
Frequently Asked Questions (FAQ)
Q1: Why do Risk Adjustment and Quality programs often remain siloed?
A: Silos usually result from structural, cultural, and operational differences. Risk Adjustment teams focus on retrospective coding and revenue capture. Quality teams prioritize prospective care gap closure and Stars measures. Each function uses different vendors, reporting processes, and success metrics. Without deliberate integration strategies, these workflows remain disconnected.
Q2: What are the regulatory implications of combining Risk and Quality workflows?
A: Integrating workflows does not change regulatory obligations. Diagnoses still require proper clinical documentation, and care gap closures must comply with HEDIS specifications. Unification improves traceability and audit readiness, since documentation and member interactions are centrally managed. It is critical to maintain clear data lineage and adhere strictly to CMS and NCQA guidelines.
Q3: How does data normalization help integration?
A: Data normalization ensures that diverse data sources such as claims, EMR, lab feeds, and supplemental files are standardized into consistent, structured formats. This process enables accurate mapping between ICD ten codes, HCC categories, and HEDIS measures. Without normalization, analytics engines and outreach systems often produce incomplete or conflicting outputs.
Q4: What technology is required to enable an integrated workflow?
A: At a minimum, plans need a central data aggregation and processing platform to ingest and normalize inputs. They also require an analytics engine to identify suspect conditions and care gaps, workflow tools to coordinate outreach and manage tasks, and reporting dashboards that consolidate performance metrics across risk and quality functions. Many organizations build these capabilities on modern data lake architectures with secure role-based access.
Q5: How does integration improve member experience?
A: When teams coordinate outreach, members receive fewer redundant calls or letters. Instead of separate interactions about coding verification and care gaps, members get unified communications with clear next steps. This reduces confusion, improves satisfaction, and increases engagement rates, which positively affects CAHPS scores and Stars performance.
Q6: What results can health plans expect from integration?
A: While results vary by organization, plans that successfully align Risk and Quality programs often see higher RAF scores through more complete coding, improved Stars ratings from greater care gap closure, reduced compliance risk because documentation is aligned with coding, and better operational efficiency along with less member abrasion.
