Ask four people on a PACE leadership team how risk adjustment is going, and you’re likely to get four different answers.
The CFO is looking at last month’s reconciliation. The CMO is looking at chart audit results from last quarter. The risk adjustment lead is looking at pending submissions. The ED is looking at whatever report landed most recently.
Often, none of them are wrong. They’re just not looking at the same data.
This makes a simple question surprisingly hard to answer: How are our risk adjustment operations actually performing?
Everyone has part of the answer. No one necessarily has the whole picture.
It feels odd that we spell this one out but not the others.
The problem isn’t lack of data
PACE programs aren’t short on data. Too often, they’re short on connection. A condition can be identified in one system, documented in another, submitted by a TPA, and reconciled against payment data later. The information is there, but the full story isn’t in one place.
Eventually, finance notices a number that doesn’t look right. Operations sees a backlog. Clinical leadership sees a documentation gap. And someone has to start digging into the chart, into the submission report, into CMS status, into the payment data.
This is a hard way to manage something as important as risk adjustment.
Three questions. One connected story.
To manage risk adjustment well, leadership needs to answer three questions:
- What opportunities are we missing?
- What happened to what we found?
- What’s the financial impact?
These questions have lived in different systems, owned by different teams, answered at different times. This makes it difficult to connect a missed connection to a submission problem, or either one to a change in revenue.
Our upcoming release of IRIS risk adjustment brings them together for the first time. It builds on the revenue capture capabilities PACE programs already rely on and adds visibility into the CMS submission pipeline and the organization’s financial performance.
1. What opportunities are we missing?
Risk adjustment starts before the assessment. IRIS pre-encounter preparation (PEP) analyzes clinical and eligibility data to surface potential HCC and RxHCC conditions before annual and semi-annual assessments. AI does the initial work. Onshore certified risk adjustment experts validate every suggestion for accuracy and compliance.
Instead of asking clinicians to sift through a chart for every possible opportunity, IRIS gives them a focused list of risk-adjustable conditions to review.
But identifying a condition is only the beginning of risk adjustment.
2. What happened to what we found?
Once a condition is documented, it still must make it through submission and CMS processing before it affects payment. A condition can be documented correctly and still fail to become revenue. With multiple handoffs, programs can be left waiting without knowing where a submission stands.
Very soon, IRIS will give programs complete visibility into the CMS pipeline from submitted and pending to accepted or ineligible—and shows why.
Typically, whenever a risk adjustment lead sees a rejected submission in a report, they have to move between the submission report, the chart, encounter information, and other systems to figure out why. With IRIS, they can see the rejection, the reason, the participant, the underlying encounter and the condition in one place.
Knowing the submission status alone isn’t enough; programs need to understand the financial consequence resulting from each submission.
3. What’s the financial impact?
The next question is the one leadership ultimately needs to answer: How is risk adjustment affecting our financial performance?
Very soon, IRIS will connect risk adjustment activity to financial results:
- Monthly per member per month (PMPM) revenue over time
- Risk adjustment factor (RAF) trends
- Views by organization, provider, IDT, and participant
- Drill down to participant, condition, encounter, or submission driving a change
When revenue or RAF shifts, leadership doesn’t need to open another spreadsheet or wait for the next report to trace the variance. The answer is already ready in the IRIS dashboard.
Now leadership can move from “revenue is down” to “where did it change,” and then “what is driving the change?”
This is a very different conversation.
One team. One view.
This is the bigger idea behind the upcoming release of IRIS. Revenue capture, CMS submission tracking, and financial analytics aren’t three capabilities bolted together. They’re three parts of the same risk adjustment story, united in a single platform built for PACE.
When everyone sees the same connected story, teams capture opportunities earlier, resolve issues faster, and understand what’s driving financial performance.
This is what changes the conversation.
Instead of: “My report says…” “Our audit shows…” “We’re still waiting on…”
The discussion shifts to: “Here’s what we’re seeing. Here’s where the gap is. Here’s what we need to do.”
From chart to ledger, nothing gets lost in the shuffle. This is what IRIS is designed to do. Because visibility isn’t the only goal. Better control is.
And maybe the next time someone asks, “How’s risk adjustment going?” you won’t get four answers. You’ll get one.
Want to see how IRIS changes things for your seat at the table?
Download the IRIS CEO/ED one-pager.
Download the IRIS CFO one-pager.
