Case Study: a large regional insurer improves risk adjustment accuracy with Optum

a large regional insurer strengthens risk adjustment with Optum through earlier, point-of-care intervention

A large regional insurer faced increasing regulatory scrutiny and sought to move beyond retrospective reviews to improve risk adjustment accuracy earlier in the care journey. They partnered with Optum to implement a more proactive approach.

Optum's solution involved shifting risk adjustment efforts upstream by embedding risk insights into provider workflows through EHR-connected tools and point-of-care gap closure. They tailored strategies for different providers and leveraged automation and AI to prioritize opportunities and manage coding volume. This partnership with Optum helped the health plan build a scalable, point-of-care model to strengthen governance, compliance and mitigate RADV risk.