RiskAnalyzer™

Medicare Revenue Optimization
In 2007, the Centers for Medicare and Medicaid Services (CMS) completed the phase-in of risk-adjusted payments for Medicare Advantage plans based on the CMS Hierarchical Condition Category (CMS-HCC) model.  The goal of risk adjustment was to pay Medicare Advantage (MA) and Prescription Drug Plans (PDPs) based not only on member demographics, but also on their health status so that funds would be distributed in a more equitable fashion.  Health status is determined by the diagnoses recorded by providers on administrative claims and therefore inaccurate and/or incomplete coding can significantly reduce a Medicare Advantage health plan’s revenue. 

DSTHS RiskAnalyzer™ was designed to use claims experience to determine where provider coding is not capturing disease conditions under the CMS-HCC model.  It provides an objective set of rules to prioritize provider and member records for chart audit through identification of potentially incomplete or inaccurate patterns of coding - either retrospectively or prospectively.  This review is imperative because over time, plans with strong coding review programs will gain revenue at the expense of plans with no or ineffective coding review.

Transparent Multi-Source Rule Types
RiskAnalyzer makes available a comprehensive set of clinically based rules derived from historical medical claims and pharmacy information to assist you in qualifying pursuits based on the probability of receiving a premium increase.

Succeeding with Providers: Quality Coding and Quality Care
RiskAnalyzer provider reporting provides a mechanism for evaluating potential premium increases – based on provider coding inconsistencies and inaccuracies – with drill downs to member-level and claim-level information to substantiate potentially successful pursuits. The transparent nature of the rules help define specific instances of coding variations that may inform provider education programs and help to reduce the perpetuation of on-going coding inaccuracies.

Risk Analysis
Even though there may be fairly definitive evidence of a condition, CMS requires that the physician record the appropriate diagnosis; if it is not in the chart, the probability of revenue recovery is reduced.  For this reason, it is imperative that health plans look forward and support appropriate member management while there is still an opportunity to maximize next year’s revenue. 

• Mid-year, identify members without encounters while there is still time to deliver quality care
• Determine members where CMS-HCC is not adequately capturing financial risk by focusing specifically on pharmacy data which is explicitly excluded from the reimbursement model using the Johns Hopkins ACG® risk adjustment system.

Comprehensive Medicare Solution
Successful management of a Medicare program considers both financial and clinical components.  While revenue optimization is imperative, it needs to be done in the context of the delivery of high quality care which adheres to industry recognized care guidelines.  DSTHS RiskAnalyzer can be seamlessly integrated with the DSTHS CareAnalyzer™ modules to support a more complete member assessment – identification of high risk members, co-morbid conditions and gaps in care. 

Competitive Advantage

• More strategically evaluate suspect claims based on the likelihood of a premium increase using transparent, multi-sourced rules
• Evaluate provider coding patterns to reduce the perpetuation of on-going inaccuracies and to improve the quality of care delivered
• Maximize next year’s revenue by identifying mid-year variances while there is still an opportunity to support appropriate member management
• Understand your true financial risk with external comparisons to the Johns Hopkins ACG risk adjustment system.

For more about DSTHS RiskAnalyzer™, contact us at inforequests@dsthealthsolutions.com.