risk-adjustment-support

What problem does it solve?

This Skill addresses the complexity and financial risk associated with inaccurate Hierarchical Condition Category (HCC) coding and Risk Adjustment Factor (RAF) score calculations in healthcare.

Core Features & Use Cases

• HCC Gap Identification: Pinpoints conditions documented but not coded, leading to lost revenue.
• RAF Score Optimization: Validates existing scores and identifies opportunities for accurate improvement.
• RADV Audit Preparation: Ensures documentation supports claimed HCCs, mitigating audit risks.
• Use Case: A Medicare Advantage plan can use this Skill to analyze claims and clinical notes, identify patients with diabetes who have documentation supporting a more specific HCC code (e.g., diabetes with hyperglycemia), and quantify the potential RAF score increase and associated revenue uplift.

Quick Start

Analyze the provided diagnosis claims and member demographics to identify potential HCC coding gaps and suggest improvements.