RISK ADJUSTMENT TECHNOLOGY
Outcomes Health provides Best-In-Class risk adjustment solutions
Healthcare organizations, including Medicare Advantage plans (MA, MA-PD and SNP), require fiscal fitness tests to remain financially viable. Outcomes Health provides an end-to-end risk adjustment solution that accurately captures members’ health status through proper HCC (Hierarchical Condition Categories) management.
Outcomes Health’s HCC Management program is an efficient, integrated system to keep clients competitive and compliant by ensuring their HCC-based average Risk Adjustment Factor (RAF) score matches their members’ actual health risk. Outcomes Health makes this possible through ODIS ALERT™ – our Web-based service – which applies intelligent, transparent and customizable algorithms. It validates membership and identifies those with chronic conditions, including those with potentially under-reported conditions and/or those with gaps in care.
Outcomes Health then performs retrospective clinical audits of medical records to correct past coding inaccuracies, and engage in prospective activities that support sustainable improvement organizations’ Medicare Advantage programs. Each module is integrated, providing a seamless solution.
Outcomes Health takes steps to ensure that we are compliant, following CMS specifications and RADV rules. QA analysts check our coders’ work on a daily basis. Our Clinical Audit Team stays informed by attending industry conferences and user group calls. Our HCC Management Program begins with an analysis of the risk profile of your plan’s membership. We will also systematically identify gaps in coding, which can indicate gaps in care, as well as CMS compliance issues.
Retrospective recovery involves identifying and retrieving medical records for members who are most likely to have incomplete, inaccurate and/or missing codes. The medical records retrieval process is centrally coordinated. We deploy a national network of Field Reviewers (RNs and certified coders) to scan medical record documents on-site then transmit that data to our secure document servers. To ensure that retrospective coding inaccuracies are corrected, all medical records are reviewed by our most experienced clinical auditors and are subject to a rigorous quality assurance review to ensure high quality risk adjustment data is reported on a consistent basis.
Prospective activities include education for providers about HCC and correct documentation and coding practices, as well as the proactive management of high-risk members who need an evaluation performed.