Opportunity BasketRisk Adjustment Audit & Remediation Service (Managed Service)
A specialized audit firm that conducts deep-dive retrospective reviews of MA payer diagnosis coding across 12-24 month lookback periods, identifies coding inflation and misapplication against CMS risk adjustment rules, quantifies exposure, and delivers a remediation roadmap with corrected coding submissions and compliance protocols. The service includes quarterly re-audits and real-time escalation protocols for high-risk coding patterns.
32 weeks • 70% confidence
Value Proposition
Proactive identification and correction BEFORE CMS audits, reducing settlement exposure by 60-80%; demonstrates good-faith compliance effort to regulators; eliminates guesswork in interpreting complex risk adjustment coding rules; delivers quantified financial impact upfront so payers can reserve and remediate rather than face surprise penalties
Target Audience
Medicare Advantage payers (regional and national insurers) with 50K+ MA members; compliance and medical coding leadership; CFOs managing fraud risk
Key Features
- Retrospective claims-level audit against CMS HCC coding rules and documentation standards
- Quantified exposure report: over-coded diagnoses, unsupported HCCs, documentation gaps by provider/facility
- Corrected coding submission templates ready for resubmission to CMS
- And more, with full implementation detail...
Tech Stack
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Healthcare payers struggle to accurately apply risk adjustment coding standards and face massive fraud penaltiesMedicare Advantage payers like Independence Blue Cross are paying millions in settlements due to diagnosis code inflation and misapplication of risk adjustment standards, creating compliance nightmares. Billing and coding teams lack reliable systems to validate coding accuracy against complex MA risk adjustment rules, leading to unintentional fraud exposure and devastating financial penalties. Current manual review processes and legacy systems fail to catch coding errors before they trigger government investigations.
Score: 58.0% • 1 payment signal