Risk adjustment software solutions for healthcare organizations
The Milliman MedInsight Risk Adjustment Platform is a comprehensive healthcare risk adjustment software solution that helps organizations optimize performance across value-based care. It supports risk adjustment analytics, HCC documentation and coding, prospective and retrospective workflows, quality initiatives, and financial risk management to improve accuracy, compliance, and reimbursement outcomes.
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The Challenge: Navigating complexity for optimal outcomes
Managing risk adjustment, clinical documentation, and quality of care can be complex and demanding. These processes involve many detailed steps and require a deep understanding of both the clinical and financial sides of healthcare. This is because accurate risk adjustment is crucial for balancing fair reimbursement and optimal patient outcomes in value-based care settings. Without the right insights and processes, healthcare organizations may fall short, leading to critical errors such as:
- Inaccurate risk scoring
- Inefficient HCC documentation and coding
- Undocumented or untreated conditions
The Milliman MedInsight Risk Adjustment Platform
Healthcare risk adjustment software for enterprise risk management
We understand that successful risk management goes far beyond point solutions. Our integrated, enterprise framework breaks down the silos between retrospective, prospective, quality, and population health strategies—ensuring every department collaborates effectively for the greatest impact on your bottom line and patient well-being.
The Milliman MedInsight® Risk Adjustment Platform provides a comprehensive solution combining industry expertise, proven technology and the industry’s most reliable data to improve care, reduce costs, and confidently manage financial risks. With options that include turn-key implementation or flexible use, our solutions are tailored to provide the level of support you need. MedInsight’s risk adjustment technology connects data, analytics, reporting, and workflow tools to help healthcare organizations improve documentation, monitor risk, and manage financial performance.
Who MedInsight serves
Whether you operate in Medicare Advantage (MA), Accountable Care Organization (ACO), Affordable Care Act (ACA), Medicaid, or Commercial markets, our integrated platform adapts to your environment and sets you up for success in any risk-based contract. Our normative warehouse encompasses 100% of MA, 100% of Medicare fee-for-service (FFS), 100% of Medicaid, and approximately 50% of Commercial claims data, allowing you to tailor interventions and evaluate competitors with precision.
Empowering MedInsight Risk Adjustment users
Risk adjustment software supports more accurate documentation and coding by helping teams monitor risk, identify provider-specific patterns, and address potential coding or documentation gaps.
Data analysts
Make informed decisions and drive financial success with our proprietary technology suite that streamlines operations, optimizes resource allocation, and ensures accurate reimbursement.
Information consumers
Gain clear insights into your financial and operational performance, and identify savings and risk reduction opportunities through simplified population analysis and stratification.
Financial users
Boost financial success and make data-driven decisions with a proprietary technology suite, designed to streamline operations, optimize resource allocation, and ensure accurate reimbursement.
Clinical users
Identify high-risk patients, support complete documentation, streamline administrative tasks, and improve patient engagement through detailed reporting that provides actionable insights into patient populations.
MedInsight risk adjustment software features
Unified health records
Access all major national data networks and integrate direct APIs to build the most comprehensive medical records and ensure no critical information is missing.
Customizable insights
Tailor reporting and filter to specific members, populations, or categories to gain granular insights and drive informed decision-making.
Seamless system integration
Effortlessly integrate structured medical record data with existing systems and workflows to enable stored queries and reports for easy future access.
Claims medical record integration
Bridge the gap between claim data and medical records to track responses and assess sufficiency of documentation, streamlining workflow and enhancing accuracy.
Enhanced coding compliance
Efficiently monitor coding compliance and HCC risk, with provider-specific insights to differentiate between isolated errors and providers needing further training.
Proactive care identification
Quickly pinpoint members requiring additional care, including in-home care or virtual visits, to improve plan Star Ratings and health outcomes.
MedInsight Risk Adjustment Platform advantages
One vendor, one cohesive strategy
Align risk and financial strategies by leveraging industry-leading normative datasets, Milliman's thought leadership in Medicare and risk contracting, alongside the MedInsight Data Confidence Model and Health Cloud Platform.
Improved accuracy and compliance
Achieve a more accurate and comprehensive view of population health statuses with our retrospective and prospective processes. Our integrated approach accelerates chart reviews and ensures adherence to regulatory requirements.
Enhanced clinical documentation and care
Correct coding errors to guarantee accurate reimbursement. Real-time data helps identify high-risk members, enabling timely interventions and improving overall care quality.
Streamlined risk adjustment and quality processes
Experience seamless integration with thousands of providers and every major EMR/EHR to keep the information you need readily accessible.
Actionable benchmarks for quick adaptation
Gain near-real-time insights to refine strategies and stay ahead of fast-changing risk adjustment variables, whether addressing ACO risk score challenges or tracking national trends in Medicare Advantage.
Strategic market insights
Gain valuable insights into market expansion opportunities, potential provider partners, and member MA product choices by geography to support your strategic decisions.
Purpose-built workflows for every department
Boost efficiency and accuracy with flexible workflows for Retrospective, Prospective, and Quality departments, combining AI with clinical rules and expert support to enhance recapture rates, and close quality gaps for maximum impact.
Frequently Asked Questions
What is risk adjustment software?
Risk adjustment software analyzes clinical and claims data to calculate patient risk scores and align reimbursement with patient health complexity.
How does risk adjustment software support risk adjustment analytics?
Risk adjustment software supports analytics by identifying high-risk patients, uncovering coding gaps, and predicting future healthcare costs to improve financial and clinical performance.
How can risk adjustment technology improve documentation and coding workflows?
Risk adjustment analytics helps organizations identify documentation gaps, monitor HCC coding accuracy, evaluate population risk, and uncover opportunities to improve care and financial performance. The MedInsight Risk Adjustment Platform improves workflows by guiding documentation at the point of care, validating coding accuracy, and reducing reliance on retrospective chart reviews.
What should healthcare organizations look for in a risk adjustment vendor?
Organizations should look for audit-ready accuracy, strong data integration, scalable technology, and tools that improve provider documentation and coding quality. Unlike risk adjustment vendors that offer isolated point solutions, MedInsight provides an integrated enterprise framework that supports retrospective, prospective, quality, and population health strategies.
How should healthcare organizations compare risk adjustment companies?
When evaluating risk adjustment companies, healthcare organizations need a partner that combines healthcare data expertise, clinical and coding knowledge, workflow integration, and support for risk-based contracts. They should compare vendors based on coding accuracy, audit defensibility, workflow support, efficiency gains, and measurable impact on revenue performance.
How can risk adjustment software support compliance and financial risk management?
Risk adjustment software supports compliance and financial performance by ensuring accurate, evidence-based coding, reducing audit risk, and aligning reimbursement with true patient acuity. Solutions like the MedInsight Risk Adjustment Platform further enhance this by leveraging Milliman’s proven actuarial methodologies to deliver consistent, defensible insights that strengthen audit readiness and improve confidence in financial outcomes.
MedInsight overview
Trust your data and accurately price risk with MedInsight: relied on by over 300 payers and ACOs since 1997 to aggregate and enrich claims data with county-level benchmarks, risk adjusters, and groupers—all peer-reviewed as part of the MedInsight Data Confidence Model. Your data will be refreshed in days instead of weeks every month so you can identify insights that lead to improved health outcomes, lower cost, and reduced financial risk.
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Best in KLAS for the sixth year
MedInsight’s platform for healthcare analytics and data warehousing was recognized as the Best in Payer Data Analytics Platforms in the 2025 Best in KLAS: Software and Services report. Best in KLAS awards are determined following extensive evaluations and conversations with thousands of healthcare providers.
Learn moreResources
Risk Adjustment Services for MA Plans
Medicare Advantage (MA) plans face challenges in accurately assessing and managing member health risks, especially as regulations and CMS guidelines change. To ensure fair reimbursement and stay competitive, MA plans need strong risk adjustment strategies and precise documentation of Hierarchical Condition Categories (HCCs), since mistakes can lead to compliance issues and lost revenue. They also … Risk Adjustment Services for MA Plans
Harnessing analytics and AI: A modern guide to risk adjustment
Value-based care (VBC) models are reshaping the delivery, measurement, and funding of healthcare at an accelerated pace, making precise risk-adjustment processes essential for ensuring that reimbursements and premiums accurately reflect actual care costs. Accurate risk adjustment creates a fair and sustainable link between healthcare costs and provider compensation in risk-sharing arrangements. To succeed requires careful … Harnessing analytics and AI: A modern guide to risk adjustment
Genesys PHO: Optimizing patient risk stratification and clinical outreach
Genesys PHO, a Michigan-based physician hospital organization and partnership between primary care physicians and investors Ascension and Henry Ford, serves about 120,000 patients. Recently, the organization began working to improve outcomes using risk stratification to improve provider performance. Working with analysts and leveraging the risk stratification tools in the Milliman MedInsight VBC Platform, nurses embedded … Genesys PHO: Optimizing patient risk stratification and clinical outreach
Preparing for HEDIS 2025 with an integrated risk adjustment solution
Are you ready for HEDIS 2025? Streamline your workflows with an integrated risk adjustment solution Every year, the National Committee for Quality Assurance (NCQA) publishes a detailed list of updates, additions, and deletions for the Healthcare Effectiveness Data and Information Set (HEDIS®).1As one of the most critical sets of performance measures in the healthcare industry, … Preparing for HEDIS 2025 with an integrated risk adjustment solution
Integrated risk adjustment solutions: Enhancing reimbursement and patient care
Accurate risk adjustment is essential for fair reimbursement and optimal patient care in value-based care. However, issues like inaccurate risk scoring, poor HCC documentation and coding, and undocumented or untreated conditions can create a large burden for both payers and providers, leading to expensive and time-consuming processes. In this webinar, Milliman MedInsight will explore innovative … Integrated risk adjustment solutions: Enhancing reimbursement and patient care
RISE National 2025
Milliman MedInsight will be at the RISE National 2025 conference, held from March 11-14, 2025, in San Antonio. This annual event gathers 2,000 attendees and features a diverse program covering topics such as risk adjustment, quality improvement, member experience, and social determinants of health. Visit us at the show to discover how our new Milliman … RISE National 2025
