Improving risk adjustment workflows in healthcare

Risk adjustment plays a significant role in Medicare Advantage (MA) contracts and commercial exchange plans, as well as The Centers for Medicare and Medicaid Services’ (CMS) alternative payment models.

Hierarchical Condition Categories (HCC’s) are used in contracts with MA plans. Higher HCC scores identify more complex patients and allow for additional payment from CMS to care for those patients.

Learn More About HCCs →

Risk Adjustment Factor (RAF) scores are based on diagnoses. RAF scores determine the amount paid to the organization per beneficiary during the corresponding payment year. Insurance organizations are paid at a higher rate for patients that have multiple conditions and conditions with greater levels of severity, as their anticipated costs of care will be higher.

Retrospective reviews use strict criteria to identify diagnoses that are eligible for reporting. Without retrospective review, healthcare organizations may find themselves out of compliance with HCC coding guidelines.

RADV and OIG audits are increasing. Health plans are under more pressure than ever to ensure their risk adjustment (RA) programs are accurate and efficient.

RADV audits are extremely involved and a fixed deadline is set by CMS. As a stand-alone or when combined with other Health Language Expert Solutions Suites, Health Language helps health plans standardize claims and clinical data and provides the tools for more efficient workflows, increased efficiency and production, more accurate RAF scores, higher RADV validation results, and contributing to better member care and outcomes.

Read Seven Strategies For A Successful RADV Audit →