Risk Adjustment

Ensure reimbursement for Medicare, Medicaid, and individual membership

To prepare for population shifts caused by the Accountable Care Act provisions, plans will need to develop strategies that assess financial exposure and estimate risk-based reimbursement. Plans may find it challenging to predict how much health care will cost for newly insured members, which makes the task of mitigating those costs even more difficult.

Download the form below to receive a copy of the Intense provider engagement: Prospective risk adjustment with high intensity
provider engagement
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Optum provides end-to-end support to help plans deliver high-quality care, manage increasing health care costs, and achieve payment accuracy. Our risk adjustment services help Medicare Advantage, Managed Medicaid, and Commercial/Exchange plans support accurate reimbursement while

streamlining risk management processes and assisting in improving quality of care. Through our integrated solutions, Optum helps:

  • Improve quality of care and clinical performance
  • Manage population more effectively
  • Increase provider engagement
  • Submit more complete data to the Center for Medicare & Medicaid Services (CMS) and Health and Human Services (HHS)
  • Increase accuracy and completeness of data
  • Achieve more accurate risk adjustment factor (RAF) scores
  • Understand the financial impact of submitted data and changing RAF periods



Assessments risk adjust to allow for appropriate reimbursement from CMS.

In-Person Provider Assessments are designed to identify a member’s ongoing care needs and meets CMS requirements for risk adjustment to allow for appropriate payment from CMS.