Risk Adjustment Solutions: How to Collect Clinical Data from Members

September 20, 2018 Jeanette Stern

The transition to a value-based reimbursement model is incentivizing payer-provider collaboration, as sharing clinical and claims data improves their ability to be reimbursed. Yet, until interoperability is reached with EHR and enterprise systems, this collaboration won't be operationally realized.

The good news is there are still viable ways for payers to collect clinical data for risk adjustments without reaching interoperability with providers. And, in the process of collecting clinical data, payers can improve member engagement and reduce costs significantly.


Offering Home, Virtual, and Retail Clinic Visits

Payers can collect clinical data from their members by offering home, virtual (telehealth), and retail clinic visits. Specifically, payers can use the clinical data collected from these services:


  • Comprehensive health risk assessments (HRAs)
  • Labs and ancillary services
  • Initial and annual wellness visits
  • Medication therapy management
  • Screenings and testing (Osteoporosis, Diabetes, Peripheral Artery Disease, Colorectal Cancer, Spirometry testing)
  • Post-hospital discharge visits 


The clinical data collected from these services gives payers valuable information for risk stratification, care management, and risk adjustments. By using the clinical data collected from home, virtual, and retail clinic visits, payers won't have to rely as heavily on claims data and the scant data given by providers.

Comprehensive HRAs include:


  • Confirming their PCP
  • Medical history documentation
  • Medication list and review
  • Behavioral health screening
  • Physical examination
  • Old and new HCC documentation
  • Recommendations for PCP follow-up


Offering home, virtual, and retail clinic visits to members is a viable solution for payers to collect the data needed for risk adjustments. Instead of waiting until medical problems occur and claims are submitted, payers can proactively and affordably connect with their members and collect the valuable data needed.


Reducing Costs and Increasing Member Engagement

Providing home, virtual, and retail clinic accessibility to members will also help prevent costly and unnecessary urgent care, ED, and PCP visits.

An article found on HealthPayer Intelligence called: "Can Retail Clinics Improve Patient Access, Reduce Costs for Payers?", written on June 28th, 2018 by Thomas Beaton, explains:

"Preventive care can help significantly reduce payers' healthcare costs by addressing chronic conditions before they worsen and reducing the likelihood that beneficiaries need emergency or high-cost healthcare services. The CDC estimates that avoidable chronic conditions cost the US $260 billion annually in healthcare costs.

...Retail clinic visits cost an average of $146 per visit, nearly half the cost of an urgent care visit."


In addition to collecting valuable data for risk-adjustment reimbursements, payers can significantly save money by offering home, virtual, and retail clinic visits. Reducing costs is vital for payers, especially, considering the uncertainty of reimbursement rules, as seen with the recent news of CMS suspending $10.4B in risk-adjustment payments to payers.

Additionally, payers can improve member engagement by offering home, virtual, and nearby retail clinic visits, as the aforementioned article explains:

"Healthcare payers could also generate higher consumer satisfaction with their health plans by offering retail clinic access to members.

...Fifty-nine percent of consumers said they chose a retail clinic over another primary care facility because the hours were more convenient, and 56% said that they choose to use a retail clinic because there was no need for an appointment.

Forty-eight percent of consumers said they chose a retail clinic over a primary care setting because the retail location was more convenient."


Home and virtual visits are equally, if not more, convenient for members as well. Payers can utilize all three methods to boost member engagement, collect valuable risk adjustment data, reduce costs, close Healthcare Effectiveness Data and Information Set, or HEDIS star closure gaps, and improve provider collaboration.

Payers can use a call center to connect with members initially and on an ongoing basis, in order to inform and educate them about these alternative choices, their health, and their comprehensive member services. Educational resources can also be provided to members through the mail or online.



While improving payer-provider collaboration by reaching interoperability with Electronic Health Record and enterprise systems is a good goal, payers don't have to rely on this collaboration to remedy their insufficient risk adjustment data. Rather, they can work with a company like MedXM to offer their members home, virtual, and retail clinic visits, in order to collect the valuable clinical data needed to optimally benefit from risk adjustment reimbursements, reduce costs, and improve member engagement. If interested in learning more, please contact MedXM today.


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