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.

Risk Adjustment Factor (RAF) Compliance Optimization is a vital and proactive solution for all payor classes (Medicare, Medicare Advantage, Medicare Shared Savings Plans (MSSP), Medicaid, Commercial – Insured and Employer Self-Funded Plans, and other Risk Based Reimbursement Plans).

CMS's Risk Adjustment Data Validation (RADV), Transactional Coding of Diagnoses Final Rules, and Nation Quality Strategy (NQS) requirements are now in effect and have and will continue to create a significantly higher risk of an audit and could have a serious impact on reimbursement. 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.

Compliance is Now Incentivized

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, 98% are NOT meeting RAF compliance benchmarks and targets.

Administrators even boast about their 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’s reimbursement has been reduced or why you 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 to happen to you!

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.

Hospitals and physicians are paid by MA plans and ACOs based on patient RAF Scores. It’s a fact that physicians struggle with having enough time to complete MA plan/ACO requirements related to the redocumentation of diagnoses. This can negatively impact the accuracy of patient RAF Scores.

To drive higher reimbursement, providers often seek to identify diagnoses which will result in a higher patient RAF Scores. This requires focus on the coding of a patient’s diagnoses, 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.

MA plan providers and ACOs use a variety of methods to increase patient RAF Scores. One approach is to review a patient’s medical record, typically after the patient encounter, to identify opportunities for “upcoding” a diagnosis to raise scores. For example, if a diabetes diagnosis can be coded as having neurological manifestations, the risk score will be higher, as will the reimbursement.

Just a quarter-point increase in a patient RAF Score translates into an extra $3,000 per patient per year to an MA plan or ACO and higher reimbursement and/or shared savings for the provider.

There are a flurry of software products coming to and on the market claiming to help identify opportunities to optimize or manage risk, but in reality, 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.

Tech and Data is the Key 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.

The Provider Tune Up Platform advanced systems effortlessly navigates the complexities of patient diagnostics to optimize patient RAF Scores. The 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 condition, but also informs you of the required assessment and treatment plans. The result shall be accurate and compliant RAF Scores that drive revenue growth. And with the platform handling of oversight, scheduling, and billing or billing assistance, your focus can remain on excellent patient care.

The comprehensive RAF Compliance technology covers all four of the 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 the TIN, physician, and Health Plan with maximum reimbursement.

What About ACO Reach?

Trying to accomplish this under an ACO REACH model will prove to be a mistake. Because you can’t drive the metrics needed to identify patient complexity, and thus assure a risk-sharing lift, without top performing patient data. The performance metrics from our platform will provide a significant boost in risk shared revenue while lowering overall costs.

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 to HCC & ICD codes are kept up to date to ensure correct coding and reporting based on updated diagnoses. As rules evolve, so does the platform, keeping you always ahead of the curve.

Increase Revenue Opportunities

The platform can also create more ancillary service opportunities for you, such as:

• Annual Wellness Visits
• Chronic Care Management
• Remote Patient Monitoring
• Behavioral Health Integration
• Commercial Wellness Prep
• Principle Care Management
• And more

The First Step is Patient Outreach

To achieve or maintain top RAF performance, mandated and incentivized assessments based on each patient treatment care plan and their medical necessity is the tip of the spear for meeting compliance and obtaining insights into patient complexity.

The Bottom Line

You need a professional service that will deliver 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.

The Provider Tune Up Platform will make the efficient management of patient care as easy as 1-2-3. It Reflects the Health Status of a Patient Population Accurately and Compliantly, Which Makes It a Vital Tool for All Providers.

You need a professional service that will deliver 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. And this is exactly what we deliver.

Our platform will make the efficient management of patient care as easy as 1-2-3 and can create the increase in reimbursement you desire. It will empower 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. In addition, allow you to act upon information immediately and satisfy potential Quality Care and CMS/MA audits.

It Reflects the Health Status of a Patient Population Accurately and Compliantly, Which Makes It a Vital Tool for All Providers. 

Unlocking Financial Rewards starts with a RAF Verification Analysis.

To determine the best course of action, we must first find out exactly where you are hitting and where you are missing. We will utilize publicly available CMS data, and data you supply us from your ACO, MA Plan(s), Electronic Medical Records (EHR) system, Practice Management System, and/or other manual sources. The execution of a BAA is required.

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 manhours to complete. Within two business days, we will be ready to discuss the finding and recommendations with you via a Zoom call and present the RAF Compliance Optimization Strategy Report. This report will identify any compliance gaps & vulnerabilities and provide the most effective recommendations and solutions.

Our Provider Partner is the leading firm specializing in the processes of Patient Engagement, RAF Compliance, Healthcare Technology, Data Analytics, and Business Management Services for financial ROI.

They support thousands of independent and hospital-based physicians & clinicians, multi-TIN organizations, ACO members, and Medicare Advantage plan providers. They possess a knowledgeable team of people that handle all necessary tasks and provide frequent reporting and useful analysis.

In a 30-minute Zoom call, we will talk more about the RAF Verification Analysis and how much more revenue we can help you can capture.

Take a few moments to download our RAF Compliance Optimization flyer, the 2024 CMS RADV Final Rule Changes, the NQS, and our NCND. Complete and email it to: support@livewellaps.com. Then reserve a Zoom call with us.

1. Click Here to download the 2024 CMS RADV Final Rule Changes (pdf).
2. Click Here to download the NQS 2024 (pdf).
3. Click Here to download our Mutual NCND (pdf).
4. Click Here to go to our Calendly page to reserve a Zoom call (complete the required fields and when asked “purpose of call,” click: RAF Compliance).