We offer comprehensive strategies for health plans.
Health plans, providers and patients can feel the weight of risk adjustment programs due to inefficient, burdensome processes.
Our experience with the largest Medicare Advantage database of medical records in the industry informs artificial intelligence (AI):
- Suspecting: chronic conditions, new manifestations, complications, interactions
- Identification, stratification and targeting of both risk adjustment and quality care needs
By chart volume, Optum is the leader of Medicare Advantage risk adjustment chart retrieval. We use AI to enable chart retrieval by identifying the modality (analog or direct EHR) deemed most likely to be retrieved successfully from providers. This helps eliminate wasting time requesting charts from providers that can be retrieved digitally.
- Scale: retrieve 12 million+ charts annually
- Efficiency: EHR direct connections for chart retrieval to 150K+ providers
- Familiar provider experience: 100,000+ connected facilities, 15,000+ embedded clinics, and 3,000+ embedded hospitals
Coding and QA
Our global team of AAPC- or AHIMA-certified coders receive rigorous training and quality assurance to ensure maximum data capture and accuracy.
- Integrated artificial intelligence improves accuracy and efficiency, largely eliminating the need for redundant reviews
- Coding and abstraction accuracy of over 95% annually*
- Global staffing options to support variable demand year-round
- Configurable QA options to support business requirements
We provide end-to-end management of submissions, direct errors and remediation. Insights promote continual improvement to maximize accuracy.
- Proven EDS submissions since the CMS program inception in 2011
- MA RAPS/EDS submission services to CMS
- HHS EDGE Server submission services
Preparing for and undergoing a CMS or HHS RADV audit can be a massive task. Optum provides comprehensive data validation and support services to health plans for CMS and HHS RADV audits. We also provide internal data validation review services for clients performing self-audits and claims verification services for claims submitted to CMS and HHS.
- CMS & HHS RADV audit services
- CMS & HHS claims verification services
- Internal data validation review services for clients performing self-audits
Reporting and Insights
Optum leverages the latest business intelligence technology to deliver web-based, flexible, customizable and plan-specific insights.
- Business intelligence with comprehensive near real-time weekly, monthly and end-of-project reporting
- National disease prevalence reporting
- Program value and attribution reported by provider and member attributes
- Technology to oversee the Optum operation, and workflow tool to support health plan operations
How wasteful is your retro risk program?
For health plans subject to performing risk adjustment, their retrospective risk adjustment process may be costly, inefficient and wasteful in many ways:
- Wasted resources and expense when managing multiple vendors
- Unnecessary provider abrasion caused by retrieving unproductive charts
- Disrupting providers with manual chart retrieval and review
- Manual coding can miss potential unreported diagnosis codes and leave coding accuracy incomplete
The key to efficient chart review is minimizing disruption to the provider workflow to increase participation and enhance long-term relationships.
Managing risk with diverse and deep expertise
Optum uses its diverse and deep expertise to transform the chart review process. Optum artificial intelligence (AI) modernizes the process by shifting the focus from volume of charts targeted to precision targeting of charts.
AI-enabled components of the Optum comprehensive retrospective risk adjustment solution enable a smart, highly efficient retrospective chart review process.
Improve accuracy and completeness with one vendor
Improve efficiency, reduce expense and maximize accuracy and completeness — all from one vendor. As a full-service retrospective risk adjustment vendor, Optum can take all your data and:
- Run AI-enhanced analytics
- Retrieve charts (digital or analog)
- Review charts
- Submit to HHS or CMS on your behalf
- Help with HHS claims verification or throughout a CMS RADV audit