Medicare Risk Adjustment

oversee, optimize and enhance

While understanding the complete risk-adjusted profile of your member population can impact significant variations in revenue, it also requires more detail than claims data alone can provide. Verscend’s Medicare Risk Adjustment solution offers users an integrated set of tools to perform all stages of a Medicare risk adjustment program, from suspect targeting and data validation to encounter data submission and
audit support.


Suspect Analytics

Our proprietary model helps identify members with suspect conditions and possibly undocumented conditions appropriate for prospective and retrospective targeting. This model individually considers HCCs and other factors that may indicate treatment of an unreported condition. Our Medicare Advantage plan clients' revenue per chart is roughly 50 to 60 percent higher for charts recommended through our suspecting process than those identified by the plans themselves.

Medical Record Retrieval

Our web-based medical record retrieval and imaging solution allows retrieval staff to group, prioritize, and initiate medical record requests with the least possible amount of disruption to providers and their office staff. Our typical Medicare Advantage plan client retrieval success rate is 85 percent of completed records, even for facilities with large numbers of records to be retrieved.

Medical Record Coding

The success of a risk-adjusted program is often determined by the identification of undocumented HCCs within targeted medical records. Verscend is able to securely deliver medical records to our best-in-class certified clinician coders who have an in-depth understanding of risk adjustment coding environments and specific CMS rules and guidelines. Our Medicare Advantage clients received a total of $279M in risk adjustment payments from CMS during the 2015 project year as a result of our retrospective medical record coding.

Prospective Health Assessments

Verscend's nationwide network of nurse practitioners performs in-person health assessments at members' homes, skilled nursing facilities, and provider offices to document all conditions important for risk adjustment, quality, and care management initiatives. Our Medicare Advantage clients received $213M from our prospective coding.

RAPS & EDS management

Verscend provides our technology coupled with subject-matter experts to reduce the time and cost involved with accurately submitting Risk Adjustment Processing System (RAPS) and Encounter Data System (EDS) files to CMS.

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