Case Study: Large Medicaid Health Plan increases risk score and achieves 7:1 ROI with Optum

Risk Adjustment Strategy Allows Large Medicaid Plan to Increase Risk Score

Large Medicaid Health Plan, a Western U.S. Medicaid plan with more than 500,000 members, needed to improve its risk score. The plan partnered with Optum and used the Change Healthcare RISK View system to apply advanced analytics and coordinate a 12-person provider relations team for targeted risk-adjustment outreach.

Optum worked with the plan to develop prospective outreach strategies and a dedicated project manager to target members with large risk-score gaps (TANF Adult/Child and SSI) and those not recently seen or without documented chronic conditions. Using Optum’s RISK View to manage member/provider targeting and data, the program materially increased documented risk scores and revenue, delivering an estimated overall ROI of 7:1 and multi‑million dollar estimated revenue impacts (for example, roughly $9.5M from prospective outreach and $2.5M from chronic-condition outreach).