Risk Adjustment Solutions for Health Plans and Providers

Improve risk-adjusted revenues in Medicare, Medicaid, and ACA markets with our risk adjustment solutions for thorough, accurate, and compliant risk capture.

Risk Adjustment Services for Accurate Financial Performance

Raising the average risk score of just 100 beneficiaries by a fraction of a point yields a six-digit boost in annual risk-adjusted revenue, underscoring the value of optimal risk capture. For payers and provider organizations that support Medicare Advantage, Medicaid, and Commercial Exchange plans, achieving accurate and compliant risk documentation and scores is integral to remaining financially competitive. At AAPC Services, we understand that risk adjustment determines health plan performance and elevates provider profits. Our solutions will maximize your risk adjustment accuracy and help you meet your revenue goals. We specialize in surfacing opportunities for better risk adjustment program performance and are committed to ensuring you receive equitable compensation for the health conditions, health status, and demographics of your beneficiaries.

Prospective Risk Adjustment Chart Auditing

Timely and equitable risk-adjusted pay involves looking ahead to gauge how your patients� health will evolve. With our Prospective Risk Adjustment Chart Auditing, you�ll generate more value from your risk adjustment analytics. Our team of certified auditors and medical coders will identify gaps in care, assessment, and clinical documentation � and help you realize better outcomes as we equip your physicians for optimal patient monitoring and point-of care decisions, informed of chronic conditions and suspected HCCs. Rely on AAPC Services to capture your members� risk burden and improve your risk score accuracy.

Prospective Risk Adjustment Chart Auditing

Retrospective Risk Adjustment Chart Auditing

Our retrospective risk adjustment solutions drive better risk scores and improved compliance, helping to raise your risk-adjusted revenue and reduce your CMS RADV audit risk. AAPC Services� trademark quality controls maximize coding completeness while verifying that diagnoses are supported. To ensure accurate risk capture, our highly experienced retrospective teams review patient encounter data in the clinical documentation, to look for diagnoses and conditions missing from original claims. Our flexible services range from focused audits for target populations and specific HCCs to end-of-year sweeps.

Retrospective Risk Adjustment Chart Auditing

Concurrent Risk Adjustment Chart Auditing

With AAPC Services� concurrent review, we integrate our risk adjustment team into your workflow to ensure HCCs are captured correctly on encounter claims. Our coders review for under-documented risk opportunities and verify that all codes and conditions are accurate and supported by documentation that meets HCC coding requirements. Missed diagnosis codes are then updated within the workflow, prior to claim submission. Our concurrent risk adjustment audits offer a proactive solution to retrospective review deadline management and can effectively trim the intensity, cost, and error potential of annual sweeps.

Concurrent Risk Adjustment Chart Auditing

RADV Audit Services & IVA Services

  1. Trial-Run RADV Audit Services

    The threat of a Risk Adjustment Data Validation (RADV) audit failure and the associated extrapolation of errors can significantly undermine your health plan�s financial success. But we can mitigate your RADV audit risks with our trial-run RADV Audit Service. Our risk adjustment teams adhere to the CMS model to ensure you receive reliable results. Learning your payment error estimate and your extrapolated payment recovery estimate gives you a powerful advantage. Our trial-run RADV audit will outline your substantiated HCCs, unsubstantiated HCCs, and unreported HCCs � and equip you with actionable items to secure your compliance and safeguard your risk-adjusted revenue.

  2. Initial Validation Audit (IVA) Services

    AAPC Services� integrated IVA teams have the data validation expertise to effectively lead you through the IVA process. Our extensive experience serving as the IVA entity for commercial risk-adjusted health plans means top results and top-tier quality assurance. We�ll complete your risk adjustment IVA on time and in full compliance with HHS�s requirements for validation of member demographic and enrollment data, medical claims data, and health status data.

Provider Engagement & Risk Adjustment Education

Optimal risk adjustment scores depend on coding accuracy supported by documentation that is more complete and more thorough. But the data you receive from your provider organizations isn�t as developed as the data you need to remain competitive in the marketplace. AAPC Services can help. Our Provider Engagement and Risk Adjustment Education programs are designed to bridge the gap between your health plan and your providers. While nurturing engagement and a sense of partnership, we make sure your providers have the training and support � and motivation � needed to implement RA best practices. We help establish processes to tract suspects, follow through with patient outreach, and optimize documentation and coding.

HCC Coding

Changes in risk scores directly affect health plan revenue. While state-of-the-art natural language processing and artificial intelligence technologies streamline risk adjustment coding, it�s the unmatched efficacy of highly skilled certified coders that achieves the biggest gains in risk capture and compliance. At AAPC Services, our risk adjustment coding teams facilitate thorough code capture, verifying that all appropriate conditions are identified and properly supported. Our experience extracting diagnoses that substantiate disease and comorbid condition data means your health plan can rely on us to capture severity levels and secondary manifestations. You can also count on us to perform quality assurance of all coding results to ensure your submission to CMS is accurate, optimal, and compliant.

The Advantages of AAPC Services� Risk Adjustment Solutions

  • We offer a full menu of risk adjustment services and customize our solutions to meet your needs, whether you�re a small physician practice, a mid-size health plan, or a multi-hospital health system.
  • Our industry expertise includes RADV experience and working with health plans, capitated health systems, ACOs, provider groups, and other healthcare delivery models. Our teams specialize in risk methodologies, such as:
  • CMS-HCC Model
  • DxCG Model
  • Medicare and Medicaid CDPS Model
  • HHS HCC Model
  • ACO Model
  • ESDR Model
  • PACE Model
  • Hybrid Risk Models
  • Each year AAPC Services audits 300,000+ medical records in more than 40 specialties � and maintains a 98% accuracy rate.
  • Through our risk adjustment services, we find undocumented chronic conditions in approximately 95% of the medical charts we retrieve, review, and code.
  • Without exception, we double-down on every service. Quality assurance is our culture, it�s who we are, and it�s our commitment to you.