HCC Predictive Risk Adjustment Solution

HCC Predictive Risk Adjustment Solution

Taking Risk Out of Reimbursement

Leverage advanced data analytics to create a more complete picture of the complexity of your member HCC risk and improve premium capture while maintaining compliance.

The VitreosHealth HCC Predictive Risk Adjustment (PRA) Solution is the ideal tool for a HCC coding analyst. It can help in every step of the process from identifying an undercoding opportunity to generating a provider-query form and then getting members’ chart data reviewed and ready for RAPS file submission. The VitreosHealth HCC PRA Solution can also help your organization predict the premiums you will receive from the CMS taking some of the risk of reimbursement out of the whole process.

Right Coding

Adaptive, learning Extract-Transfer-Load (ETL) process to scout EMR, claims, billing, pharmacy, lab results, ADT, Mental Health, HRA files to create a 360-degree longitudinal view of the member record Disease specific predictive modeling platform to capture any emerging complications with chronic disease progression Multi-dimensional OLAP model to propagate chronic condition diagnosis from a 3-year history Proprietary prioritization algorithms rank order members based on the number of unidentified, undercoded diagnosis codes, type of codes, HCC & MLR changes, and revenue impact for chart reviews by the HCC coding analysts to maximize coding accuracy with minimum member chart reviews

Transforming a typically fragmented process

By using the Vitreos HCC PRA, you have an organized and data-driven approach to develop a HCC risk work plan.

Identifies undercoding & overcoding opportunities to:

  • Increase payment
  • Capture true risk
  • Medical Loss Ratio (MLR) reduction
  • Avoid compliance issues

An integrated solution for various users:

  • Highly efficient and productive tool for chart auditors and analysts
  • Easy documentation for audit & compliance professionals
  • Performance reporting tool to enhance transparency for senior management

Integrated workflows with embedded analytics increases productivity and revenue capture

  • Built an easy-to-use, intuitive, minimal click web-based HCC Review insights app
  • Leveraged the Predictive Modeling platform run disease specific chronic disease models to identify and capture any emerging chronic condition related complication with disease progression
  • Developed a “RAF Opportunity Score” based on number of unidentified, under-coded diagnosis codes, type of codes and revenue impact by member to prioritize members for chart reviews by the HCC analysts