Risk Adjustment Solutions

Help ensure compliant, accurate compensation
for your members' risk

Driving value for Medicare Advantage and commercial health plans

Risk adjustment programs are complex. Their successful management requires ensuring your health plan’s risk is appropriately captured, documented, and compliant—all without sacrificing efficiency. The regulatory environment changes frequently, and government audits are becoming more common. You need a partner with in-depth risk adjustment experience, one that you can depend on and trust.

Cotiviti provides comprehensive risk adjustment services, combining unique subject matter expertise with natural language processing (NLP) and other advanced technologies to optimize risk revenue capture as well as compliance. We provide full transparency at every stage, so that you can always track the status and performance of your risk adjustment programs.

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Delivering greater value, innovation, and partnership

Our Risk Adjustment solutions help drive compliant, accurate results with in-depth expertise, advanced technology, and complete quality assurance processes. Our solutions drive impact across key areas:

Metrics that
matter

>$2B

average appropriate incremental risk adjustment revenue delivered to clients annually

Ensuring scale
and capacity

>10M

charts coded annually

A commitment
to quality

>97%

average coding accuracy

Cotiviti's Risk Adjustment solutions

Deploy expert risk adjustment solutions to help ensure optimal and appropriate reimbursement. Click on each icon below to learn more.

 

Suspect Analytics

Effectively identify members with suspected but potentially undocumented conditions

Starting your risk adjustment program with a strong analytics foundation is key to improving efficiency and results. However, identifying the right priorities can be a challenge. Cotiviti's Suspect Analytics solution helps identify members with potentially undocumented conditions, as well as risk and probability of success, to optimize your efforts. Our advanced analytical models provide our clients with a nuanced examination of their data, predicting which members have the highest probability of missing or incomplete conditions. Our solution enables plans to:

  • Leverage advanced analytics to effectively create your chase list
  • Identify charts with higher risk and potential value
  • Reduce time and effort to manage and analyze data

Learn more about Suspect Analytics

 

Medical Record Retrieval

Improve risk adjustment results while minimizing provider abrasion

Health plans need to acquire, exchange, and share large volumes of clinical data to support appropriate reimbursement and drive quality member care. A successful retrieval solution operates efficiently at scale and allows health plans to conduct outreach in a coordinated, minimally intrusive manner using a range of options from EMR integration to traditional mail and fax.

Cotiviti's Medical Record Retrieval solution offers comprehensive, web-based medical record retrieval, aggregation, indexing, and storage. It features strong digital data exchange capabilities and interoperability strategies, which combine with Cotiviti's expertise in leveraging traditional channels such as fax, email, and phone to help address gaps or barriers and optimize results. Medical Record Retrieval allows plans to:

  • Gain the latest provider insights, historical data, preferences, and locations
  • Tailor methods to optimize the retrieval process and prioritize provider requests
  • Track requests in real time with detailed notes and alerts from Cotiviti retrieval agents

Learn more about Medical Record Retrieval

 

Medical Record Coding

Accurately capture and document risk-adjustable conditions

Medical record coding is complex, with guidelines and requirements that are constantly changing and evolving. Health plans need a partner to reduce complexity and manage coding compliantly, efficiently, and effectively at scale.

Cotiviti’s Medical Record Coding solution enables health plans to accurately capture their population risk while delivering high quality results. Leverage natural language processing (NLP) technologies, integrating them with our teams' expert leadership, an in-depth understanding of the healthcare industry, and our proven best practices to:

  • Strengthen quality processes with clinical and technical knowledge enhanced by the latest technology innovations
  • Improve accuracy with relevant codes and clinical context in extensive certified coder chart review
  • Reduce compliance risk with data analytics that can catch complex conditions and severity levels

We also offer Second Level Review for charts previously coded, enabling health plans to add a layer of protection and optimize results by integrating our coding and quality assurance expertise.

Learn more about Medical Record Coding


Suspect
Analytics

Medical Record
Retrieval

Medical Record
Coding
 
 

 

 

Download the Risk Adjustment brochure