Use Case #4 for our HCC RAF Score Tools

How to Select High-Value Charts for Retrospective Review in Risk Adjustment Coding?

Problem:

The current approach to selecting charts for prospective review presents significant shortcomings. Charts are typically chosen randomly or by comparing current versus past fiscal year (FY) claims solely based on total revenue. These methods are inherently flawed and can result in high-revenue charts being overlooked, leading to substantial revenue losses.

Our Solution:

Rather than relying on random selection or crude revenue comparisons, we advocate for a comprehensive analysis of current and past FY claims data. Our goal is to uncover hidden revenue opportunities that might otherwise go unnoticed. This can be achieved by analyzing the demographic and diagnosis data from the current financial year with that of the past financial year using CMS HCC RAF score models, factors, and Medicare Advantage payment.

Flow Diagram to Select High-Value Charts for Retrospective Review in Risk Adjustment Coding

Our RAF Batch Scoring tool has been specifically designed to meticulously scrutinize individual ICÌs from both current and past FY claims using non-PHI data demographic and diagnosis data, CMS HCC RAF score models and factors and then it provides informed recommendations on which high-value charts warrant further scrutiny during retrospective review

Benefits:

Maximized Revenue Capture:

The most significant advantage of our approach is the potential for maximizing revenue capture. By employing RAF Scores to analyze ICD data from current and previous years, we can identify high-value charts with a higher degree of accuracy. This ensures that no critical revenue opportunities are missed, ultimately leading to increased revenue.
Resource Efficiency:

Healthcare organizations can efficiently allocate their resources with our tool by selecting the right charts for reviews. Instead of reviewing charts arbitrarily, they can concentrate their efforts on charts with the most substantial revenue potential. This results in significant resource savings.
Mitigated Revenue Loss:

Our approach greatly reduces the risk of revenue loss. By identifying and auditing high-value charts, healthcare providers can promptly address potential revenue leakage and compliance issues, ultimately safeguarding their financial stability.
Informed Decision-Making:

Healthcare organizations can make well-informed decisions by leveraging data-driven insights from RAF score analysis. This approach empowers them to prioritize and address the most crucial revenue-related issues, leading to overall financial improvement.