For providers: Risk adjustment advisory services for primary care physicians who are contracted with Medicare Part C plans.

For payors: Industry best practices for Medicare Part C plans to comply with quality and accuracy regulations, namely:

“The Sponsoring Organization’s written contracts with first tier and downstream entities must contain the provisions that contracting providers agree to safeguard beneficiary privacy and confidentiality, consistent with all Federal and State laws, and ensure accuracy of beneficiary medical, health, and enrollment information and records,” as provided for in 42 C.F.R. § 422.118; Manual Ch. 11 – Section 100.4

Services

  • Gain share / quality bonus payments and Medical Loss Ratio calculations
  • HCC Groupings and RAF Score calculations
  • Creating visibility into lawful, legitimate methods to avoid dropped codes and diagnoses that lead to lost revenue

ICD-10 HCC Groups

Mapping of diagnosis codes to HCC groupings under ICD-9 (ICD-10 has different groupings)

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