How to Tell If a Risk Adjustment Vendor Is Actually Good (Or Just Good at Sales)
I’ve sat through enough risk adjustment vendor demos to know the script by heart. Every vendor claims they’re different. Every demo shows impressive accuracy rates. Every case study features glowing testimonials. By the third meeting, they all sound identical.
But some vendors are actually good. Some are just good at selling. Here’s how to tell the difference before you’re locked into a three-year contract you regret.
The Demo That Reveals Everything
Most risk adjustment vendors show you their platform using sanitized demo data. Perfect documentation, clear diagnoses, obvious HCCs. Everything works beautifully. Of course it does. They’ve been showing this exact demo for months.
That demo tells you nothing useful. Instead, bring your own data to the evaluation. Not just any data. Bring your messiest, most problematic charts. The handwritten notes from the geriatric practice. The 50-page hospital discharge summary. The encounter where the provider listed fifteen diagnoses but didn’t document MEAT criteria for any of them.
Watch what happens. Good risk adjustment vendors handle messy data gracefully because they’ve built their systems to deal with reality. Bad vendors fumble around or make excuses about why your data doesn’t work well with their platform. If they can’t handle your actual charts during the demo, they won’t handle them in production.
The Technology vs. Process Split
Here’s something most health plans get wrong: they evaluate risk adjustment vendors based on technology features. How sophisticated is the AI? What’s the user interface like? Can it integrate with our EHR?
Technology matters, but process matters more. A vendor with mediocre technology and excellent processes will outperform a vendor with cutting-edge technology and chaotic processes.
Ask about their coding workflow. How do charts move from intake to final submission? What happens when a coder is uncertain? How do they ensure consistency across multiple coders? What’s their escalation path for complex cases?
Good risk adjustment vendors have clear answers because they’ve refined their processes over thousands of charts. Bad vendors give vague responses about “best practices” and “experienced coders” without explaining the actual workflow.
The QA Question That Separates Winners from Losers
Every risk adjustment vendor will tell you they have robust quality assurance. Here’s how to verify it.
Ask this: “Can you show me an example of a systematic error you caught through QA in the last six months, and walk me through how you fixed it?”
Good vendors can immediately pull up a real example. “We discovered that one of our coders was consistently missing MEAT criteria for CKD documentation. Our QA process caught it after about forty charts. We retrained the coder, went back and reviewed all their recent work, and implemented an additional check for CKD specifically.”
Bad vendors get defensive or give generic answers about “continuous improvement” without specific examples. If they can’t describe actual errors they’ve caught and fixed, their QA process isn’t as robust as they claim.
The Contract Terms Nobody Reads Carefully
Risk adjustment vendor contracts have language that sounds innocuous but creates huge problems later. Pay attention to these specific terms.
Data ownership. Who owns the coded data, the evidence trails, and the audit documentation? Some vendors claim ownership of work product, which creates complications if you switch vendors or need to produce audit evidence years later.
Termination clauses. What happens if you want to leave? Some contracts lock you in with auto-renewal clauses and heavy termination fees. Others give you clean exit paths. This matters because if the relationship isn’t working, you need to be able to get out.
Performance guarantees. Some vendors guarantee accuracy rates or productivity levels. Great, but read the fine print. How is accuracy measured? What happens if they miss the targets? Most “guarantees” have so many qualifications that they’re meaningless.
Service level agreements. How quickly do they respond to issues? What’s considered an urgent versus routine request? When your coders are stuck waiting for vendor support and can’t make submission deadlines, you’ll care a lot about these SLAs you didn’t read carefully.
The Reference Call That Actually Tells You Something
Vendor-provided references will always give positive feedback. They’re selected because they’re happy customers. That doesn’t make the calls worthless, but you need to ask the right questions.
Don’t ask “Are you happy with the vendor?” Ask “Tell me about a time when something went wrong and how they handled it.” Every relationship hits problems. What you want to know is how the vendor responds when things break.
Don’t ask “Would you recommend them?” Ask “What surprised you about working with them, positive or negative?” This gets past the rehearsed talking points and reveals the actual experience.
And here’s the sneaky one: “If you were selecting a risk adjustment vendor today, knowing what you know now, what would you do differently in the evaluation process?” This tells you what they wish they’d known before signing.
The Real Differentiator
After evaluating dozens of risk adjustment vendors, here’s what actually separates the good ones from the rest: how they handle uncertainty.
Bad vendors pretend everything is straightforward. Their coders are confident about every decision. Their technology never struggles with ambiguous documentation. They make coding look easy.
Good vendors are honest about uncertainty. They’ll tell you “this documentation is borderline, here’s why, here’s how we’re handling it, and here’s the audit risk.” They’re comfortable with ambiguity because they deal with it constantly.
Risk adjustment isn’t clean. Documentation is messy. Clinical judgment varies. MEAT criteria is subjective. Vendors who acknowledge this reality and have processes to manage it are the ones you want. Vendors who pretend it’s all figured out are selling you a fantasy.
