Use Case #2 for our HCC RAF Score Tools

Optimizing Revenue and Efficiency: Strategies for Identifying High-Value Codes and Charts in Prospective Coding

Problem:

The effectiveness of prospective coding hinges on precise chart selection, yet numerous hospitals encounter challenges. Misconceptions about choosing the right charts often contribute to this struggle. Many hospitals prioritize high-revenue Fee-for-Service patients, overlooking the potential lack of HCC linkage in these ICDs, leading to suboptimal revenue outcomes. Relying on year-to-year ICD comparisons and delta-based prospective coding can result in overlooked ICDs with already covered HCCs. These challenges in prospective coding strategies lead to inefficient resource use and suboptimal revenue outcomes. A proactive approach is crucial to enhance revenue accuracy, streamline prospective coding, and reduce unnecessary coding costs.

Our Solution:

Leveraging sophisticated risk models, our advanced system precisely analyzes individual ICDs from both current and past fiscal year claims, and calculates Risk Adjustment Factor (RAF) Scores and forecasts Medicare Advantage (MA) payments for each ICD/HCC, generating comprehensive revenue impact analysis reports. Efficiently filtering high-revenue HCCs and charts, these tools optimize prospective coding and CDI efforts, enabling hospitals to confidently select and target high-revenue charts and HCCs. This results in a significant reduction in coding and CDI costs, all without requiring PHI and charts.

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

This approach emphasizes high-impact charts and codes, enabling hospitals to confidently target high-revenue HCCs for prospective coding, effectively reducing coding and CDI costs and optimizing revenue outcomes.

Benefits:

Optimize Revenue:

Utilize CMS HCC RAF Scores and Medicare Advantage payments to precisely identify high-value charts from current and previous years' demographic and ICD data, preventing revenue oversights.
Efficient Resource Use:

Our risk analysis tools enable healthcare organizations to allocate chart review resources wisely, focusing on high-revenue impact charts for significant time and resource savings.
Decrease Revenue Loss:

Swiftly address potential revenue leakage and compliance issues by identifying and auditing high-value charts, ensuring minimal revenue loss for healthcare providers.
Informed Decision-Making:

Data-driven insights from RAF Scores and Medicare Advantage payments aid healthcare organizations in prioritizing and addressing critical revenue-related issues, enhancing overall financial performance.
Eliminate Chart Dependency:

Our solution removes the need for charts, leveraging non-PHI demographic and diagnosis data from claims to streamline revenue management processes.