Risk Adjustment Audit Validation and Reporting Services

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Risk adjustment is a growing source of untapped profit potential; however, meeting CMS’s reimbursement requirements requires intensive resources. The guidelines associated with risk documentation standards require the submission of meticulously chosen and verified data for the risk scoring of patients (i.e. patient risk profiles).

The payer has the responsibility to provide the risk score information to CMS. The payers, in turn, are dependent on the physicians’ to diagnose and properly link the document for each high risk patient according to a strict protocol of necessary information needed for reimbursement. Working together, MiraMed can aid providers in understanding and providing the required documentation according to risk model methodology.

MiraMed provides:

  • Retrospective Risk Adjusted Data Validation (RADV) Auditing 
  • Concurrent Chart Auditing 
  • Risk Adjustment Educational Programs (CMS-HCC, HHSHCC, Commercial Exchange and Medicaid Managed Care) 
  • Physician Scorecards tracking Annual Wellness Visit Completion
  • Member Outreach
  • Annual Health Care Cost Assessment Program

Retrospective Chart Auditing

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MiraMed has a robust, thorough process for conducting retrospective auditing which involves reviewing documentation and encounter data on past dates of service (within the current or previous reporting year) that have already been submitted through the clearinghouse to health plans.


Services included:


  • Review dates of service within the current year, improving outreach potential of members prior to completion of each reporting year.
  • Avenue for reviewing documentation and data from previous risk adjustment reporting years prior to final closure date deadlines by CMS.
  • Specialized focused audits for selected populations of patients and/or specific HCC categories prior to sweep dates.
  • Ongoing educational opportunities for primary care physician (PCP) and staff based on findings within retrospective audits.
  • Validate functions for diagnostic codes previously submitted by providers.
  • Upon request, submit code corrections forward (additions and deletions) to health plans upon completion of review.

Annual HCC Assessment Program

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Yearly, face-to-face, annual HCC assessments by practitioners for the evaluation and medical management of patient chronic conditions play a significant role in the maintenance of quality clinical practices. MiraMed will facilitate the program entirely or implement the program so that the providers can manage the program internally.

Note: The office medical assistant can help the physician prepare for the visit by getting a list of the diagnostic codes previously used for reference.

Services included:

  • Prospective auditing review process based on the providers tracked yearly annual HCC assessment (internally) on charge encounters. Risk adjustment auditors at MiraMed facilitate this documentation review process prior to billing. 
  • Establish a workflow that includes the ability to schedule appointments with sufficient time for practitioners to review chronic conditions, update medication lists, update problem lists and counsel patients on health issues during the visit.
  • Work with your EHR via optimization to determine the ability to annotate completion of annual HCC assessment within the areas for electronic record.
  • Auditors advise practitioners to add diagnostic codes to the patient’s problem list based on documentation review so that the diagnosis is verified by practitioners at a subsequent visit.
  • Collaborate with your internal systems and reporting to conduct ongoing reports for all members per PCP panel who have had an annual HCC assessment within a given year and also those patients who have not been assessed for outreach purposes.
  • Facilitate reports to be sent out monthly to providers regarding percentage rate attainment for completed annual HCC assessments per medical group, per site, per PCP (with enhanced graphing).
  • Advise administrators to offer an incentive to PCP groups based on annual HCC assessment rates of completion. 
  • Completion of the annual wellness visit (AWV) (Medicare AWV is a member benefit) can take place at the same time.

Practioners receive satisfaction when maintaining quality patient care, providing ongoing services and improving chronic condition follow-up with their patients.

Member Outreach

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MiraMed will develop a tailored internal program to do member outreach. This involves an active appointment tracking program as well as outreach based on on-going practitioner face-to-face visits yearly.

Services included:

  • Create, within the workflow for practitioners, a seamless way to review the yearly health status per member.
  • Identify the member populations per health plan for medical group practitioners.
  • Identify new members per health plan which will improve assignments and expedite appointment scheduling with PCP.
  • Identify and maintain each PCP individual panel for their HMO senior population.
  • Improve tracking of member visits for annual HCC assessments per PCP.
  • Facilitate increased communications involving administration and practitioners at medical sites (i.e., through monthly action reports) by identifying upcoming visits with opportunities for chronic medical condition recapture.
  • Seek involvement by office staff with ongoing HCC program initiatives and opportunities for assisting in member outreach.
  • Provide practitioners with ongoing statistics during the year of Annual HCC Assessment attainment per PCP/site/medical group.
  • Ability to actively outreach members prior to closure of reporting year, when necessary.

Primary Care Physician Scorecards

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MiraMed provides individual practitioners with ongoing progress reports and feedback scores based on HCC reporting per member within their panel as well as peer comparison rates.

Services included:

  • Best practices to increase communication of risk adjustment factor (RAF) increases/decreases per member over a three-year period.
  • Scorecards will provide a direct demonstration of progress in reporting specified HCC chronic conditions.
  • Multiple comparisons for improving progress on average RAF scores by PCP, by medical group or by site.
  • Help to determine educational needs per PCP/medical groups.
  • Advise medical directors and administration of areas for improvement and facilitate planning specific initiatives.

MiraMed believes that keeping practitioners engaged and involved in a system-wide HCC program is what will make the client a success.

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