Healthcare

Medicare Advantage (MA) Risk adjustment

Maximize your organization’s performance with our expert-enabled risk adjustment optimization framework, designed to achieve efficient and effective program

About

Medicare Advantage (MA) risk adjustment is used by the Centers for Medicare and Medicaid Services (CMS) to ensure that MA plans are fairly compensated for the health risks of their enrolled beneficiaries. By adjusting payments based on the health needs of the population, MA risk adjustment aims to promote equitable and efficient healthcare delivery within the Medicare Advantage program.

Advantages

Optimize revenue

  • Uncover at least 2-6% of overlooked revenues

  • Enhance reporting for capturing customer interactions

  • Increase income and compliance in payment process

Prioritize resource

  • Identify high-impact areas that deliver the most value

  • Uncover trends and opportunities in provider performance

  • Allocate resources to areas with the greatest clinical need

Lower compliance risk

  • Reduce audit vulnerabilities by 4-6%

  • Ensure documentation supports submitted conditions

  • Remove unsupported claims based on risk assessment

Solutions

CMS-RADV & OIG Mock Audits

RaLytics’ Mock Audits provide MAOs with a unique opportunity to identify specific operational challenges, gain familiarity with audit and sampling procedures, and obtain a realistic estimate of audit liability.

  • Experience all aspects of the two audit approaches.
  • Get an estimate of financial impact from each type audits at both sample and extrapolated levels.

Payment Cycle Optimization

The RaLytics payment cycle framework enables a consistent and compliant submission delete strategy that improves revenues while providing predictability.

Medical Record Evaluation

  • The RaLytics platform ingests medical record documentation, scores records based on likelihood to support diagnosis for risk-adjusted payment and delivers insight reports designed to guide or validate payment submissions.
  • RaLytics offers a medical record review team to perform targeted reviews to validate client in-house coding. RaLytics’ AAPC certified coders leverage our proprietary multiple review workflow to validate all evaluations and ensure highest finding accuracy.