As healthcare organizations navigate shrinking margins, rising regulatory scrutiny and increasing member expectations, the need for synergy between risk adjustment and quality improvement teams has never been more urgent. What was once a strategic advantage is now a financial imperative.
Why alignment matters more than ever
Historically, risk and quality have operated in silos — each with distinct metrics, teams and objectives. But the current environment demands a unified approach. Aligning these functions can:
- Maximize ROI on every member interaction
- Reduce redundancies and internal competition for resources
- Improve both revenue and Stars performance simultaneously
- Enhance member experience by streamlining communications and interventions
By working cross-functionally, risk and quality teams can ensure that every member touchpoint counts. Partnering with risk starts with shared opportunities — like closing care gaps during in-home assessments. These touchpoints are ideal for addressing overdue screenings. From there, aligning outreach for Annual Wellness Visits ensures members receive one clear, coordinated message, improving both compliance and trust.
Build the foundation for coordination
When we partner with health plans and recommend more collaboration across quality and risk the response we get can be summed up as, “Great, but how?” The concept sounds good, but the steps to achieve cross-functional quality and risk work is daunting.
The four key areas of collaboration health plans should focus on are:
- Data sharing: Leveraging shared datasets to identify members overdue for screenings or care interventions.
- Outreach coordination: Aligning campaigns to close gaps in care without overwhelming members with duplicate messages.
- Provider engagement: Coordinating strategies to support providers in meeting both documentation and care quality targets.
- Unified tools: Using the same analytics platforms, targeting lists and vendor solutions to ensure consistency and efficiency.
This integrated approach not only avoids duplicative outreach but also provides a more cohesive and respectful experience for members — building trust and improving outcomes.
RADV audit expansion raises the stakes
A recent announcement of expansion of Risk Adjustment Data Validation (RADV) audits by CMS adds urgency to risk and quality collaboration. Previously conducted on a small sample of Medicare Advantage (MA) contracts, these audits will now include all eligible contracts from 2018 to 2024.
To enforce this, CMS has ramped up resources—hiring nearly 2,000 employees (up from just 40) and deploying advanced technologies to accelerate the process.
What this means for health plans:
- Greater financial risk from audit findings and potential fines
- Tighter timelines for data validation and documentation
- Increased pressure on both risk and quality teams to ensure accuracy and compliance
In this climate, disconnected teams are not just inefficient — they're a liability.
Your plan’s call to action
Aligning risk and quality is no longer a matter of operational preference; it’s a financial necessity. Organizations that break down silos, unify technology and data use, and coordinate strategies will be better equipped to withstand regulatory scrutiny, enhance member satisfaction, and drive sustainable revenue and performance.
In the era of audit expansion and budget contraction, unity is strength — and it starts with risk and quality working together as one.
How Healthmine brings quality and risk together
Quality and risk teams need a framework in place to come together — which is where Healthmine’s Quality Relationship Management™ QRM® platform comes in. This dynamic plan-facing tool provides:
- Flexible reporting your teams can act on. Find the care gaps, then action those members.
- AI-driven patient scheduling. Some studies show that less than 20% of eligible Medicare patients received AWVs. Hands-off scheduling for members alleviates one of the biggest barriers to care — getting an appointment.
- Separate, but coordinated, rewards. Quality and risk teams can and should be incentivizing members to visit their providers, especially the members who need more support in closing this gap. Our rewards programs allow quality and risk teams to administer a singular, coordinated rewards program but still maintain separate reporting needs and budgets, so they can work smarter together.
- Enhanced outreach visibility. It is impossible to improve the member experience and gap closure when teams don’t know what the other is doing. Start sending member outreach from the same platform to improve visibility and coordinate messages.
Ready to see how we make it happen? Let’s talk about aligning your teams the right way.
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