Medicare Advantage Risk Score Accuracy

Risk adjustment(RA) payments are critical to Medicare Advantage plans to ensure that they are properly compensated for the higher costs associated with treating beneficiaries that have significant or chronic health conditions.  The HCC Risk Adjustment model used by CMS to identify these conditions relies solely on the accuracy of the diagnoses that are captured from provider claims and encounter data.  Unfortunately, provider billing practices still focus primarily on procedure coding and less so on diagnoses.  This means that without an effective risk adjustment/risk score accuracy program, the data that CMS uses in their model to calculate your payments is likely incomplete and/or inaccurate.   If incomplete, your likely being under paid.   If inaccurate, your likely receiving improper payments and are at risk for the adverse consequences that might result from the regularly conducted CMS Risk Adjustment Data Validation Audits(RADV).

For the past ten years we have been providing risk adjustment related services for health plans and risk bearing health providers.  Put our experience and expertise to work for you to help you improve an existing program or to provide you with support to establish a comprehensive solution.

  • Data analysis to identify beneficiaries with potentially under-reported and/or inaccurate reported conditions
  • Medical record acquisition (options include via request by mail, remote access to an EMR, and /or onsite visits)
  • Chart review by RA experienced, certified medical coders
  • Review results captured electronically, including inaccurate, unsupported conditions with details
  • Robust reporting and results submission capabilities
  • Flexibility to limit impact on provider community and accommodate any special affiliations you have with providers
  • High integrity service that is focused on improving the accuracy of your risk score and not risk score optimization

Contact us today! (504) 315-5998