Synopsis
As the healthcare industry moves toward value-based care, accurately representing the risk profile of each patient becomes critical for appropriate compensation. Risk Adjustment Coding ensures that providers are reimbursed based on the severity and complexity of patient conditions, especially in populations with chronic illnesses or multiple comorbidities.
However, achieving accurate Risk Adjustment Factor (RAF) scores is challenging due to inconsistent documentation, missed diagnoses, and lack of coder-clinician alignment. At Orgusta, we specialize in Hierarchical Condition Category (HCC) coding and documentation reviews that improve accuracy, uncover hidden risk factors, and help providers stay compliant with CMS and HHS regulations
Best Practices: Maximizing Accuracy and Compliance
✅ Deploy HCC-certified coders trained in Medicare Advantage, ACA, and Medicaid models
✅ Implement AI-assisted tools to identify unreported conditions and documentation gaps
✅ Conduct periodic risk adjustment audits to uncover trends and improve accuracy
✅ Provide clinician education and queries to improve documentation capture
✅ Deploy predictive analytics to identify high-value encounters and optimize interventions
Tangible Expected Results: Financial and Operational Improvements
✅ 10–20% increase in RAF scores through accurate and complete coding
✅ Higher reimbursements for managing complex, high-risk patient populations
✅ Reduction in audit risk by ensuring documentation and coding compliance
✅ Improved accuracy in forecasting patient costs and outcomes
✅ Stronger alignment with CMS HCC model and VBC initiatives
