risk-adjustment-support

To identify HCC coding gaps, you analyze diagnostic claims and clinical notes to find conditions documented but not coded. This process pinpoints missed risk adjustment opportunities and quantifies potential RAF score increases for accurate revenue recovery.

RAF score calculation under the CMS-HCC v28 model applies specific logic to diagnostic coding and member demographics. This validates existing score accuracy and identifies opportunities for compliant improvement by ensuring documented conditions map correctly to payable categories.

The best way to prepare for a RADV audit is to validate that clinical documentation fully supports claimed HCCs. Analyzing claims data ensures coding accuracy and mitigates financial risk by confirming documentation gaps are closed before audit submission.

Yes, you can analyze risk adjustment opportunities for Medicaid managed care, Medicare Advantage, and ACA plans. The process reviews diagnostic coding and claims data to validate RAF score accuracy and ensure compliant revenue integrity across these programs.

A key limitation is that claims data alone may not capture the full clinical nuance needed for accurate HCC coding. Cross-referencing with detailed clinical documentation is required to ensure conditions are specific enough to support the claimed RAF score and survive audits.