How confident are you in your Medicare Advantage and ACA Risk Scores ?

For many MAOs, risk-adjusted revenue makes up over 80% of total Medicare Advantage revenue.
— Milliman Sept. 2016 Medicare Advantage and The Encounter Data Processing System

Risk adjustment(RA) payments are critical to ensure that health plans, or risk bearing providers, are properly compensated for the higher costs associated with treating beneficiaries that have significant or chronic health conditions.  Risk Adjustment models rely heavily on the accuracy of the diagnoses that are captured from provider claims and encounter data.  Unfortunately, provider billing practices don't always focus on capturing all of the detailed diagnosis information that is so critical to these models.  This means that without an effective risk adjustment program, the data that is used to calculate your payments is likely incomplete and inaccurate.   If incomplete, you are likely being under paid.   If inaccurate, you could be receiving improper reimbursements that you might be required to pay back as a result of a Risk Adjustment Data Validation Audit (RADV).  Even worse submitting unsupported information could lead to findings of fraud and lawsuits.

We here at Gentry Consulting can help you improve the accuracy of your risk scores, identifying both under and over reported conditions, so that you know that your payments are accurate and that you can rest comfortably that you not exposed to the risks of inaccurate data.  Having performed risk adjustment services since the very beginning (2006), we have developed an extremely effective and accurate risk adjustment program that provides accurate results, improves revenues, while substantially reducing the cost normally associated with a high quality risk adjustment program.