Evolent Health Services

Risk Adjustment and Quality

Drive Smarter Interventions with Powerful Risk Adjustment and Quality Capabilities

Your organization faces unique challenges. Whether you’re dealing with poor coding behaviors, labor-intensive chart retrieval activities, or siloed risk adjustment and quality coding initiatives, our customizable programs are built to address your needs.

We offer a comprehensive and robust set of technology solutions and services to enhance your risk adjustment and quality initiatives. Leveraging machine learning models to accurately identify and prioritize opportunities across your network, our services model focuses on maximizing program efficiency and minimizing provider abrasion.

Keys To Our Success

  • Incentive development and coding education to increase physician engagement
  • Strategy experts and seasoned operators to drive results
  • Machine learning algorithms to predict undocumented diagnoses
  • Natural language processing to support chart review
  • Multiple methods for coding and care cap delivery, including EMR integration

Unlock Success With Prospective-Led Risk Adjustment

We believe in prospective-led risk adjustment operations that deliver financial results, effectively engage providers, and develop proper coding practices at the source. Traditional resource-intensive chart review relies entirely on evaluating documentation after the patient encounter. Our robust prospective operation alerts physicians to evaluate coding gaps during the patient encounter.

These opportunities enable improved coordination of care for the member, better referral practices amongst your network, and maximized overall program efficiency. 

Analysts and Actuaries Dedicated to All Risk Adjustment Lines of Business
Our experts help inform program strategy, monitor operational performance, forecast results and expected premium impact, alert partners to the impact of coming policy changes, and provide customized support for partner-specific needs.

Operational Models Tailored to Meet Your Needs
We offer custom-built operating models aligned to your organization’s needs. Using national, market, and even partner staff, our nimble operational structures enable execution against program goals.  

Encounter Submission and Auditing Capabilities That Minimize Revenue Loss
Whether you are a Medicare Advantage organization submitting RAPS and EDPS files, an exchange plan submitting to the EDGE Server, or a Medicaid plan submitting state encounter files, incorrectly submitted encounters result in unwanted revenue loss. We ensure encounters are proactively and appropriately identified, prioritized and remediated to minimize lost revenue.

Co-Developed Quality Intervention Strategy 

We have experience managing complex quality programs across a variety of health plans serving Medicare, Medicaid, Commercial and Exchange populations. Leveraging clinical and quality insights from our NCQA certified platform, we partner with you to develop and deploy strategies to improve quality measure performance across your organization.

  • Complete population assessments to evaluate demographic characteristics and changes over time and review historical member behavior to determine gap closure rates.
  • Identify practice and physician quality improvement opportunities and engage providers in closing care gaps through education, creative incentive programs, actionable reporting, and practice transformation initiatives.
  • Optimize provider focused governance and program structure design, and ensure all state, federal or NCQA quality regulatory requirements are met.

Evolent's Full HEDIS Offering and Services

Submission Management
Navigate the HEDIS submission process with confidence

Supplemental Data
Proactively identify supplemental data opportunities

Hybrid Optimization
Optimize hybrid record collection and abstraction, while ensuring compliance

Dynamic Platform Enabling Integrated Risk Adjustment, Quality and HEDIS/STARS Programs

Evolent’s Risk Adjustment and Quality services are enabled through the Identifi platform. This platform integrates data from multiple sources to provide one comprehensive picture of your member population and delivers insights at the point of care.

  • Prioritized Workflows: Create prioritized workflows and custom campaigns, by provider and practice groups, that track coding and care gap assessments throughout the year.
  • Integrated Risk Adjustment and Quality Insights: Manage coding and care gaps opportunities in simplified and consolidated views across practices, while also tracking supplemental data, chart retrieval, data submission and Natural Language Processing-driven coding and abstraction activities in real-time.

Are You Missing Out on Revenue Due to Coding Deficiencies?

Explore Related Thinking

Check out the latest insights on Risk Adjustment & Quality in our Knowledge Center