Risk Adjustment solutions

Ensure compliant, accurate compensation for your
members’ risk burden


Risk adjustment programs are complex, and their successful management requires maintaining complete compliance while ensuring your health plan’s risk burden is appropriately documented in medical records and encounter submissions. Knowing which risk adjustment tools to use—and when to use them—is critical to ensuring timely and consistent revenue payments. In addition, the regulatory environment changes frequently, and government audits are becoming more common. The stakes are high. You need a partner with extensive risk adjustment experience, one that you can depend on and trust.  

Cotiviti provides comprehensive, end-to-end prospective and retrospective risk adjustment services and support for health plans, combining technology, artificial intelligence (AI), analytics, and deep subject-matter expertise to ensure risk-associated revenue is optimized while maintaining appropriate compliance. We provide full transparency at every stage, so you always know the status of your risk adjustment program.


How Cotiviti helps

Identifying and optimizing risk adjustment opportunities that impact revenue

  • Reduce the time required to identify and substantiate members with the highest-value undocumented medical conditions through advanced AI
  • Validate and substantiate medical conditions for clinical assessments with providers
  • Monitor and reconcile encounter submission gaps

Maintaining good provider relationships

  • Reduce provider abrasion through extensive database and analytics logic
  • Support patient clinical care and wellness through our In-Home Assessments program
  • Provide active feedback on opportunities for improvement in coding and documentation

Effectively managing multiple, disparate technologies

  • Access records efficiently from multiple sources and systems, minimizing provider abrasion
  • Mine electronic medical record (EMR) systems for required information
  • Simplify system reconciliations

Maintaining complete compliance

  • Ensure compliance with Centers for Medicare & Medicaid Services' (CMS) guidelines and prepare for RADV audits
  • Allocate appropriate resources for process and data validations
  • Efficiently meet CMS submission timelines

Risk Adjustment blogs

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Our comprehensive Risk Adjustment solution suite allows you to use one partner and leverage your data across the workflow to optimize both retrospective and prospective programs.


incremental risk adjustment revenue annually*


medical record retrieval rate over past three years


chart coding accuracy


retrospective incremental realization rate, with an average yield of 1.11 HCCs per chart*


prospective incremental realization rate, with an average 1.26 HCCs per assessment*


acceptance for Medicare and commercial risk adjustment encounter submissions over the past three years

* Based on 2017 Medicare risk adjustment program results.

Suspect Analytics

Suspect Analytics uses proprietary models to help identify risk adjustment opportunities in the form of members with suspected conditions that are neither documented nor billed, and who therefore may be appropriate for prospective assessments or retrospective medical record retrieval and review.

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  • Suspecting is completed for all members using multiple data sources to identify gaps in documentation and care.
  • Cotiviti only recommends opportunities with value, along with the best venues to capture those opportunities.
  • Our program is powered by an advanced analytics engine using clinical rules and AI.
In-Home Assessments 

Our In-Home Assessments service ensures member conditions are accurately documented and coded to optimize plan revenues while closing gaps in care.

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  • Plans can recognize $1,000+ in incremental risk-adjusted revenue per member.
  • Completion of In-Home Assessments can impact five quality metrics directly and an additional four metrics through POC testing.
  • Members experience greater than 98 percent satisfaction with the in-home experience.
Medical Record Retrieval 

Our Medical Record Retrieval services provide streamlined medical record retrieval, aggregation, indexing, and storage to fulfill even high-volume record requests with minimal disruption to providers and their office staff.

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  • Medical chart chase logic identifies the best medical records to retrieve to validate clinical conditions.
  • Our database of 1.7M+ providers and historical information about them allows site/location logic grouping to minimize provider contacts and reduce provider abrasion.
  • We offer multiple medical record retrieval options (fax, mail, portal, EMR) to increase our retrieval rates.
Medical Record Coding 

Our Medical Record Coding services provide chart review by AAPC- or AHIMA-certified clinician coders to capture risk-adjusted medical conditions not previously reported for the measurement year (Medicare and commercial).

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  • Cotiviti found that 96 percent of the Medicare risk adjustment charts we suspected and coded over the last three years had undocumented chronic conditions.
  • Coding services include an optional comparison of claims and encounter data with coding data for both Medicare and commercial risk adjustment, a Coding Compliance Review process that reduces RADV exposure risk.
  • Coding workflow leverages a computer-assisted coding (CAC) engine, complementing our extensive professional coder network.
  • Our clients have seen 10 to 20 percent three-year average incremental realization rates across all lines of business.

Submissions are Cotiviti’s applications for Risk Adjustment Processing System (RAPS), Encounter Data Processing System (EDPS), and Affordable Care Act commercial (EDGE) submission of acceptable, risk-adjusted diagnosis codes to CMS. Submissions combines technology with subject-matter expertise to reduce the time and cost involved with RAPS data validation, RAPS claims filtering, encounter data editing, RAPS/EDPS and EDGE file submissions, data reconciliation, and financial impact analysis and reporting.

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  • Cotiviti uses a single data storage solution and platform for both Medicare and commercial risk adjustment submissions.
  • Our user interface is designed to rapidly prioritize, troubleshoot, and manage error corrections.
  • Clients can compare and reconcile EDPS and RAPS risk scores.

With more than 20 years of experience helping health plans with risk adjustment, Cotiviti manages the complexities of ensuring compliant revenue in full partnership with our clients, offering complete visibility into program progress every step of the way.

We offer a complete suite of operational and analytical reports that provide real-time program insights, allowing you to monitor member- and plan-level risk score changes while estimating financial impact. Tools such as provider scorecards also assist in identifying opportunities for provider education. And we have invested in secure network and storage solutions, with redundancy, to ensure the highest levels of protection.

But our strongest asset is our people. For risk adjustment, we deploy clinical and analytics experts in natural language processing (NLP) and machine learning, 1,000+ certified coding professionals, and more than 450 retrieval experts, all working to ensure the best possible results for our clients. Our people have an unwavering commitment to going beyond the status quo and delivering the highest levels of service and support.

The result? Performance you can count on.


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