Introduction How CMS Star Ratings are assessed The Centers for Medicare & Medicaid Services releases its quality Star Ratings each October to be applied to the next calendar year. Star Ratings show how well a Health Plan performs on specific things. The star rating system assesses health plans based on various factors, including preventive care, chronic disease management, member satisfaction, customer service, and overall member experience. These factors are often categorized into different domains, each carrying a specific weight in the overall rating. Health plans are assigned star ra ..read more

Retrospective Audit and its importance for MA organization Ensure quality care is being provided to Medicare beneficiaries Adhering to the Federal guidelines Enhance revenue cycle management Optimize reimbursements Defend against federal and payer audits, health plan denials, and malpractice litigations. Final submission of RAF scores to CMS facilitated by Retrospective Audit. Retrospective review and audit protect MA organizations from CMS penalties by performing first- and second-level reviews to validate the medical coder’s findings for mapping the final HCC summary and RAF score calcul ..read more

In humble appreciation, we acknowledge that attending conferences transcends mere networking and product showcases. It’s a profound opportunity to graciously embrace every moment as a chance to make a difference. The recent RISE National 2024 conference provided our team with such an opportunity, and we made sure to make the most of it. The RISE National Conference, a prestigious gathering in the Medicare Advantage sphere, is renowned for fostering collaboration and innovation. It covers topics like risk adjustment & audit, Care quality, member experience, and social determinants of heal ..read more

 Introduction Why Neuro-Symbolic AI Neuro-symbolic AI strives to blend the strengths of both domains Neuro Symbolic AI with a mission  Important Terms Applicable to Neuro-Symbolic AI Important  constituents of Neuro Symbolic AI The diagram below illustrates the utilization of AI techniques in imaging classification and segmentation for biomedical purposes. Neuro-Symbolic: Progressive  & Promising  Benefits of Neuro-Symbolic AI Future  Outlook of AI in the Era of Neuro-Symbolic AI RAAPID’s clinical solution engineering is  based on Neuro-symbolic AI tec ..read more

Rising To The Occasion Amidst a Collaborative Spirit         RAAPID’s Cutting-Edge Solutions Unveiled At RISE National 2024 In the rapidly shifting healthcare landscape, staying ahead is crucial for adapting to emerging. Trends and challenges, ensuring quality care and sustained progress. Indeed, RAAPID’s leadership position as an advanced risk adjustment solutions provider aligns itself with the growing emphasis on risk adjustment compliance and quality improvement, which are required to navigate the complexities of modern patient care. Certainly, over the years, It has g ..read more

As the healthcare landscape evolves, the transition to the CMS-HCC (Hierarchical Condition Category) Model V28 represents a significant shift for health plans. RAAPID, a pioneer in healthcare technology solutions, is at the forefront of supporting health plans in navigating this transition. This blog provides insights into the CMS-HCC Model V28, its implications, and strategies for health plans to effectively adapt to these changes. Understanding the CMS-HCC Model V28 Strategic Planning for Health Plans New Risk Adjustment Model Version 28 & its Impact CMS-HCC Version 28 Impacts Pati ..read more

Between 2024 and 2025, payments to Medicare Advantage plans are anticipated to increase by an average of 3.70 percent, amounting to over $16 billion in total. On Jan 31, 2024, the Centers for Medicare & Medicaid Services (CMS) released the Advance Notice outlining proposed payment policies for the Medicare Advantage (MA) and Medicare Part D Prescription Drug programs for the 2025 calendar year. This notice provides an overview of potential changes aimed at refining payment strategies within these healthcare programs for the upcoming year. The Advance Notice aligns with a proposed regula ..read more

Introduction The Hierarchical Condition Category (HCC) risk adjustment model, initially introduced by CMS in 2004, serves as a pivotal method for adjusting Medicare capitation payments to private health insurance companies offering Medicare Advantage plans. Over the years, this model has undergone refinements and expanded applications, now encompassing the risk adjustment of patients in various value-based reimbursement plans, such as ACOs, Direct Contracting (CMS), Comprehensive Primary Care Plus (CPC+), and others. What is HCC Coding & its Significance? The Hierarchical Approach of H ..read more

Clinicians no doubt play a vital role in recording patients’ conditions using HCC codes, but they shouldn’t shoulder the challenging coding aspects alone. Moreover, accurate HCC coding is vital for value-based care models and population health management. Incomplete coding can affect reimbursements and suboptimal decision-making. With the expanding scope of value-based care contracts, adopting and refining measures to close HCC gaps is the need of the hour to enhance revenue and ensure optimized reimbursement. Importance of HCC Coding underlying the risk adjustment process Hierarchical Condi ..read more

Health plans, globally have begun to realize the pompous value of Prospective risk adjustment programs, and deservedly so. Prospective risk adjustment programs authorize timely, effective interventions including the demonstration of probable gaps in care that support conditions coded to the highest degree of specificity. Paradoxically, retrospective risk adjustment programs limit the potency of code capture. A risk adjustment program that only consists of retrospective chart reviews is short-sighted and does not support the outcomes-driven, population health management which is now innate in ..read more