Unlocking new possibilities in risk adjustment

Unlocking new possibilities in risk adjustment

The healthcare industry is in the midst of transformational change, driven by the introduction of the V28 Hierarchical Condition Category (HCC) model and other related factors. This change is spurring innovation at unprecedented levels, and at Optum, we are at the forefront of this revolution. We are rapidly advancing our ability to take a wealth of data—both historical and current active data flowing through the healthcare system—and discern what areas to focus on for a particular member, population, or market. I firmly believe that we are fundamentally shifting how we think about risk adjustment and how solutions work.

Three key areas of transformation

1. Value for cost and intelligence delivery
One of the main areas of transformation is finding new ways to deliver more features and intelligence. This includes true automation, advanced AI, and machine learning. These technologies are enabling us to process and analyze data more efficiently, maximizing the value our clients receive from their investment. For example, our AI models can quickly identify potential gaps in care, reducing the need for manual chart reviews and saving both time and resources.

2. Digitization across the industry
The second area of focus is the digitization of healthcare processes. We are working to integrate our solutions directly into the healthcare workflow, making it easier for providers to access and act on our insights. For instance, we are developing APIs that can trigger requests to Optum when a patient has an upcoming appointment. We then send back any identified gaps or conditions for the provider to review during the visit. This helps enable providers with the necessary information at the point of care, without leaving their EMR.

3. Efficient service delivery
The third area of advancement is how our services are delivered. We are shifting to solutions that provide the same or better outcomes, but with faster, smarter implementation. This means leveraging AI and machine learning to assist in tasks that were traditionally manual, such as accessing medical records and documenting health conditions. Our ability to help provide the most accurate and complete picture of patient health possible is reaching new levels, not only within risk adjustment but across the healthcare industry.

The orchestration of transformation

The orchestration of all these components—whether across a patient panel, a provider group, or a health system—is crucial. Much of the manual work we've done historically is now assisted by AI, which is transforming how we deliver care. For example, our AI models can convert unstructured data from medical records into actionable insights, which are then verified by our clinical teams. This not only speeds up the process but also achieves high-quality outcomes.

At Optum, we have made intentional investments and brought in top talent to intensify our focus on product roadmaps, new solutions and program orchestration. We have a global product organization, and our teams are experts in fields like engineering and analytics, bringing a diverse set of perspectives and innovative solutions to the table. Our global reach allows us to develop comprehensive solutions that meet the needs of both payers and providers.

By focusing on value for cost, digitizing healthcare workflows and reducing people intensity, we are advocating that our solutions are efficient, accurate and compliant. Our commitment to the provider experience and our global capabilities set us apart in the industry. As we continue to innovate, we are excited to help our clients achieve their goals and deliver the highest quality outcomes.

Stay up to date on how Optum is innovating risk adjustment and quality programs here.

About Eric Haseman

Eric Haseman is a senior healthcare leader with more than 20 years of industry experience. He joined UnitedHealth Group back in 2002 and has spent the last decade at Optum in the risk adjustment and quality improvement space. He currently serves as the General Manager and Senior Vice President for the risk adjustment, quality and member engagement division.