Top-Performing TINs, Physicians, and Clinicians Should Only Utilize the Services of Top-Performing Vendors.

• Our service provider partner is the MOST qualified and the “best-in-class” at helping you bridge compliance gaps and vulnerabilities.
• Our skillset, strategies, tools, and support provide the structure that increase billing encounters, reimbursement, shared savings, and patient satisfaction.

The service provider is the leading firm specializing in the processes of RAF Compliance, Healthcare Technology, Data Analytics, and Business Management Services compliance and optimization for financial ROI.

Together we support thousands of physicians and hospital-based physicians & clinicians, multi-TIN organizations, and ACOs and possess a knowledgeable team of people that handle all necessary tasks and provide frequent reporting and useful analysis.

The MA Plan Problems All Providers Are Facing

• More than 50% of Medicare beneficiaries are now enrolled in MA plans.
• Since 2021, chronic conditions among Medicare beneficiaries have skyrocketed.
• Due to this rise in chronic conditions, beneficiaries are trapped in their MA plans. Going back to regular Medicare is not possible because they would not be able to afford their high-risk Medicare Part G Supplement insurance premiums. Without TINs taking action, this will be inevitable and cause a huge spike in lost reimbursement and write-offs.
• Providers need the best-in-class technology and support to ensure timely reimbursement and an increase in claims acceptance by MA plans.
• TINs need help negotiating better capitated agreements terms with MA plans.

CMS Final Rules

CMS’s Risk Adjustment Data Validation (RADV) and Transaction Coding of Diagnoses Final Rules create lower reimbursement and the higher risk of an audit.  In addition, the Transactional Coding of Diagnoses to support billing in a fee-for-service environment is NOT adequate to meet VBC program care requirements.

Though most TINs did a good job with meeting compliance in the past, due to complexity and the failure of vendors and health plans to provide TINs and their providers with the proper expertise, tools, and/or training, most are NOT meeting compliance benchmarks and targets.

Administrators even boast about their cost of care, robust risk adjustment, abstract coding teams, QA audit teams, and provider education. Unfortunately, too many are still apathetic about verification and action needed, because up until now, fully meeting requirements has not amounted to any significant increase in revenue. This has now changed.

So, now when ownership, boards, and/or stakeholders ask why your TIN failed to maximize reimbursement and no one can explain why or do anything about it, ignorance or apathy will not be an accepted excuse. Don’t let this happen to you!

The Mess is Huge

The underlying foundation of Value-Based Care (VBC) is not based on limiting care or quality. It’s about aligning optimal patient care with financial benefit – for the patient, for the doctor, and for the unsustainable cost of healthcare to our overall economy.

Everyone knows the high cost of doing business is being met with inadequate increases in reimbursement by CMS and increasing administrative burdens due to inappropriate MA plan practices.

This is causing physicians to struggle with having enough time to complete MA plan requirements related to the redocumentation of diagnoses. And this is negatively impacting the accuracy of patient RAF Scores.

To drive higher reimbursement, providers often review a patient’s medical record, typically after the encounter, to identify diagnoses which will result in opportunities for “upcoding”. This requires focus on coding and not necessarily on how well each condition is being managed. In other words, VBC models have created an overemphasis on coding, instead of on caring.

Why is this so important? Because just a quarter-point increase in a patient RAF Score translates into an extra $3,000 per patient per year to the MA plan and is supposed to result in higher reimbursement for the provider but often does not.

This is why you need help in the battle with MA plans. And the best way to accomplish this is with the help of a vendor that offers the “best-in-class” technology, guidance, and support.

Our RAF technology delivers results that achieve improved compliance, patient RAF Scores, patient attribution, Quality Scores, increased billing encounters and reimbursement, enhanced clinical support, outcomes, patient satisfaction, and cost reduction. In addition, help your TIN set up a support system that is successful in seamlessly integrating protocols that streamline operations and increase revenue without disruptions.

We are also dedicated to helping TINs and providers remain in control by negotiating capitated agreements for clinics to quality for an increase in MA reimbursement through negotiated rates with their MA plans.

You require a tool that empowers you with instant access to the information and data you need to manage and code each patient’s specific diagnoses – as well as create the documentation that supports the coding.

There are a lot of software products coming to and on the market claiming to help identify opportunities to optimize or manage risk, but they are just a veiled way of upcoding. They do NOT provide you with tools at the point of care for the patient; that is, properly manage, evaluate, assess, and treat a patient’s various conditions in accordance with the original intent of VBC: Improved Outcomes Through Better Management of Patient Health.

Our RAF software technology makes the efficient management of patient care as easy as 1-2-3 by reflecting the health status of a patient population accurately and compliantly.

It provides the support you require on VBC reporting and outcomes management. And with its EHR forensics, it allows you to view provider level risk scores from prior years, as well as current average risk score. You will be able to drill down to the usage of unspecified and unsubmitted coding on all patients associated with a provider.  It will show the dates of a patient’s last physical exam, next appointment, number of ER visits, number of diagnoses codes, the number of unspecified and unsubmitted coding, and the patient risk score.

Being able to view this information allows you to identify areas that need further improvement or education and is vital for getting a patient scheduled for Chronic Care conditions that need to be maintained and documented for improvement of the patient’s accurate risk score.

HCC coding directly correlates to patient’s risk scores. Specificity is key when it comes to HCC coding and documentation.  Providers must report on each patient’s risk adjustment diagnosis, and it must be based on clinical documentation from a face-to-face encounter. For HCCs to be successful, the doctor can accomplish documentation standards by utilizing four datapoint’s that must be documented for each patient:

1. Monitor signs and symptoms (disease process)
2. Evaluate (test results, meds, patient response to treatment)
3. Assess (ordering tests, patient education, review records, counseling patient and family)
4. Treat (meds, therapies, procedure, modality)

As the shift in healthcare continues to happen, our RAF platform shifts with it. Its technology application captures the importance of HCC coding and patient RAF scores. The HCC related analytics are intended to provide insights that will drive network and provider performance management on risk scoring as it relates to CMS and commercial payers.

Our platform is essential for the success of your Risk Adjustment program. It will significantly improve the communication of patient complexity and effectively predict patient healthcare cost utilization. Its financial impact is significant because it directly impacts the money your TIN receives from the largest single payer in healthcare, CMS.

In addition, it provides the potential to significantly impact both healthcare outcomes for your patients and reimbursement for your TIN. It will allow you to act upon information immediately and create accurate documentation that reflects the health status of a patient population accurately and compliantly, and it supports patient diagnosis and satisfies potential Quality Care and CMS/MA audits. And this makes it a vital tool for all providers.   

Tech and Data Are the Keys to Success

A comprehensive clinical care approach to VBC, as opposed to an approach that focuses on the transactional coding of diagnoses to maximize risk scores - requires a solution that enables you to quickly see the status of any known or suspected condition.

Our comprehensive RAF compliance technology effortlessly navigates the complexities of patient diagnostics to optimize patient RAF Scores. Its exclusive, compliance-focused intelligence retrieval technology guides credentialed intake providers through an infallible step-by-step validation process. This meticulous approach not only ensures precise documentation of each patient’s condition but also informs you of the required assessment and treatment plans. The result will be accurate and compliant RAF Scores that drive revenue growth. And with the platform handling oversight, scheduling, billing and/or billing assistance, your focus can remain on excellent patient care.

What About CMS Updates and Changes?

Our platform makes all necessary updates based on the latest version calculations for the current and upcoming CPY. Modifications to HCC & ICD codes are kept up to date to ensure correct coding and reporting based on updated diagnoses. As rules evolve, so does our platform, keeping you always ahead of the curve.

Unlocking Financial Rewards starts with a RAF Analysis to determine the best course of action. A reasonable analysis fee applies.

We will utilize data you supply us from your Electronic Medical Records (EHR) system, Practice Management System, and/or other manual sources.

You should expect to spend an hour or two working with our team to extract the data points required. The research, analysis, and report effort will take several man hours to complete. Within two business days, we will be ready to discuss the findings and recommendations with you via a Zoom call and present our RAF Strategy Report. This report will identify any

Our RAF platform is the empowering solution that covers all steps required to validate and compliantly document diagnoses driving increased audit validation and success. It will “check-the-box” that achieves or maintains top-performance. Ensuring that the complete health status of a patient is compliantly documented will provide your TIN, physicians, and health plan with maximum reimbursement.

Understanding the financial implications of RAF compliance helps in making the decision on whether to invest in optimization technology or stay the course with your own efforts - very easy.

In the 30-60-minute Zoom call, we will talk in detail about our core team and qualifications, our service options, and the analysis that will provide you with something you will be proud to show your decision makers, ownership, board, and/or stakeholders.

Click Here or see the link below to go to our Calendly page to reserve your Zoom call with us. Complete the required fields and when asked “purpose of call,” click: RAF.

Take a few moments to download our brochure and supporting materials below.

• Live Well A.P.S, RAF brochure (pdf).
• 2025 CMS RADV Final Rule Changes (pdf).
• CMS 2025 Rate Announcement (pdf).
•  Advance Notice of Methodological Changes for 2025 (pdf).
• Diagnostically Connecting Data and Diagnoses (pdf).