Solutions Risk Adjustment Analyzer

Risk Adjustment (RA) is the “soul” of capitated payments and value-based care programs of the Medicare Advantage (MA) and Affordable Care Act (ACA) plans. As of May 2022, more than 30 million Medicare beneficiaries are enrolled in MA plans and more than 14.5 million are enrolled in ACA marketplace.

Part of the Financial Explorer Suite, the RA Analyzer’s models are based on enrollee health status and demographic factors featuring real-time data pull, retrospective and prospective analysis on cost, payment and scores. CMS-HCC model strives to achieve the accurate predictive ratio of expenditures for subgroups of Medicare beneficiaries. HHS-HCC model has developed tailored algorithms for adult, child and infant population enrolled in ACA plans in every state. These models have ongoing revision to be better, with their complex variables and calculation logic are updated several times in a year. Accuracy and speed in implementing these models can make a big difference in revenue by predicting a plan or a practice’s capitation payment or fund transfer as the output results of these models.

Our technology can help you in many scenarios of RA activities, e.g., retrospective review for RADV audit, prospective scoring, reporting and education or as point-of-care HCC decision support. All data ingestion, cleaning and insights generation is done in an automated manner in near-real-time.

We provide a managed solution based on your needs with minimal work for your staff. The RA Analyzer is a comprehensive solution that connects seamlessly with your existing workflows and solutions. It is powered by automation and AI that ensures efficiencies and accuracy in the entire process.

 

End-to-End Risk Adjustment

No more fragmented solutions to address your risk adjustment needs. CloudMedx provides a suite of SAAS tools embedded in your existing platform to enable automation in data processing, to enhance decision support with risk profile and cost/payment prediction.

Some of the key components of RA Analyzer include:

 

1.  Data Integrity\Quality Checks and Integration with EMRs

• Data quality checks are performed to ensure that the incoming data is accurate and clean so that the right results can be generated
• Augment the manual data cleaning process with RPA (Robotic Process Automation)  to significantly improve the data management and pipeline
• Automated data ingestion from flat files, EHRs, claims files etc. Batch processing is also available.
• Direct integration with EHRs and other third party systems via APIs is available

 

2.  HCC Risk Analysis – Retrospective and Prospective (Score, Cost and Payment)

• ICD-HCC-Weight crosswalk functionality predicts cost of a disease condition
• Risk Calculators for Individual Members
  • Every relative factor’s score impact
  • Every step of calculation and adjustment
  • Cost and payment estimate PMPM and annually
• Batch input and output to calculate large population risk scores and payment estimates
• Risk applications in population stratification and care pathway
• Audit analysis

 

3.  Reporting, Education and Data Submission 

• Support EDS submission with standardized output reports for performance/quality reporting
• Reporting on opportunities and missing codes
• Identify providers frequently submitting diagnosis incorrectly and provide education to those providers. Re-audit to ensure compliance
• Track compliance performance

 

4.  Retrospective Chart Review, Pre-encounter Chart Review and ICD-HCC Guideline at Point-of-Care

• NLP (Natural Language Processing) enhanced pre-encounter chart review and ICD-HCC guideline at point-of-care
• Net new code identification and code recapture with tracking

 

5.  Coder Progress, Productivity, and Accuracy Tracking

• Streamline the coding process and highlight areas of improvement by tracking coder accuracy and productivity

 

6.  Closure of gaps in care and Real-time Communication

•  Omni channel patient engagement tools and human assistance available to ensure gaps closure
• AI-based automated outreach to close gaps
• Bi-directional communication between coder and CDI/provider from within the solution
• With real-time insights, the RA Analyzer supports concurrent coding protocols

 

Our EDPS Solutions can Mitigate your Risk of Data Errors, and Audit-Proof your Clinical Documentation

Our process:

• Batch input of structured claims data in csv format or in X12 837 format.
• Our algorithms apply the EDPS filtering logic according to CMS submission guidelines.
• Reports are generated for your staff to easily understand what actions can be taken before the EDPS data submission.
• Batch input of semi-structured CCDA, HL7 files that contain text clinical notes.
• Clinical notes associated with the claims are cross-verified using Natural Language Processing.
• Reports are generated when clinical notes are at risk of chart review, e.g., lack of diagnosis specificity.