This white paper is the second installment in Milliman’s two-part series examining risk adjustment (RA) as a systemwide operational capability rather than a standalone analytic function. The first paper established foundational context by defining RA, outlining program mechanics across lines of business, describing common challenges, and identifying the stakeholders involved.

This paper focuses on leading practices across key operational domains, including governance, staffing and training, provider and member engagement, medical management, data and analytics, revenue integrity, vendor oversight, and compliance. Taken together, these elements demonstrate how aligned operational infrastructure—rather than coding accuracy alone—drives compliant, accurate, and sustainable RA performance.

Key discussion points

• Leadership and strategy: Leadership sets the strategic direction and ensures the organization’s approach to RA.
• Staffing and training: Effective teams typically possess a strong understanding of healthcare data, coding practices, regulatory requirements, actuarial and financial impacts, data science, and IT operations.
• Provider relations and contracting: These functions ensure provider engagement, education, and expectations remain aligned with organizational goals.
• Data, reporting, and analytics: A robust infrastructure supports accuracy, compliance, and strategic performance of RA programs.
• Revenue integrity: A dedicated RA-focused revenue integrity strategy helps ensure accurate, compliant, and sustainable revenue.
• Member services: Collaboration with various teams optimizes plan performance and enhances member outcomes and satisfaction.
• Utilization and care management: Collaboration between care management and RA areas is essential for program success.
• Plan performance benchmarking: Key performance indicators can capture both operational and clinical metrics, such as encounter submission timelines, recapture rates, provider documentation accuracy, submission acceptance accuracy, risk-adjusted profitability by cohort, and audit error rates.
• Vendor and third-party oversight: Comprehensive oversight supports data integrity, regulatory compliance, and program effectiveness.
• Compliance: Compliance functions play a significant role in maintaining the integrity of the RA process for organizations.
• RA interactions: A systemwide process depends on the coordinated interaction of multiple stakeholders across the healthcare ecosystem.