Use Case #2 for our HCC RAF Score Tools

How to identify high-value charts for prospective review for Risk Adjustment Coding?

Problem:

The current approach to selecting charts for prospective coding review has some limitations. Charts are often chosen randomly or by comparing the total revenue of current versus past fiscal year (FY) claims. However, these methods are not optimal and can result in the oversight of high-revenue charts, leading to significant revenue losses.

Our Solution:

Instead of relying on random selection or total revenue comparisons, we recommend looking at the revenue impact by analyzing the demographic and diagnosis data from the current fiscal year with that of the past fiscal year using CMS HCC RAF score models and factors and it will provide deeper insights into revenue impact.

Flow Diagram to identify high-value charts for prospective review for Risk Adjustment Coding.

We have designed tools to precisely analyze individual IC§s from both current and past fiscal year claims using non-PHI data demographic and diagnosis data, CMS HCC RAF score models and factors and to recommend which high-value charts should be selected for prospective review.

Benefits:

Increased Revenue Optimization:

By using CMS HCC RAF Scores and Medicare Advantage payments to analyze demographic and ICD data from current and previous years, we can identify high-value charts with greater accuracy. This ensures that critical revenue opportunities are not overlooked.
Efficient Resource Allocation:

With our risk analysis tools, healthcare organizations can allocate chart review resources more efficiently. Rather than reviewing every randomly selected chart, they can focus their efforts only on high-revenue impact charts, saving time and resources.
Reduced Revenue Loss:

One of the most significant advantages is the reduction in revenue loss. By identifying and auditing high-value charts, healthcare providers can address potential revenue leakage and compliance issues promptly, ultimately protecting their bottom line.
Data-Driven Decision Making:

Healthcare organizations can make more informed decisions by relying on data-driven insights by analyzing the RAF Scores and Medicare Advantage payments. This approach enables them to accurately prioritize and act on the most critical revenue-related issues, improving overall financial performance.