Risk Score Opportunities (RSO)
More accurate risk scoring begins with RSO.
If plan members are under-coded, your organization could be taking on more risk than it bargained for — and losing revenue. Inaccurate risk adjustment factors (RAF) and risk scores can also result in higher premiums for other members in the risk pool. Wakely Risk Score Opportunities (RSO) helps ensure more accurate coding and risk scoring, using a set of exclusive algorithms to identify and prioritize members most likely to have uncoded conditions.
Finding under-coded members doesn’t have to be overwhelming.
Wakely RSO’s features simplify the task of identifying under-coded individuals:
- User-friendly design works off a basic data request, making it easy to put together periodic reports
- RSO algorithms have been calibrated separately for different markets — choose the one(s) you need:
- Affordable Care Act (ACA)
- Medicare Advantage
- State Medicaid programs using CDPS or Medicaid Rx models
- Using RSO, Wakely can analyze data at any level you need – including provider group, rate cell, region, and more (depending on data availability)
- After the algorithm examines all pieces of data together, only cases that pass a confidence threshold appear in the final exhibits
Request a consultation to learn more about RSO.
Put a risk score detective on your team.
Wakely provides a comprehensive report of RADIAL results to guide your EDGE submissions, including:
To identity under-coded individuals, as well as providers and provider groups that may have a higher proportion of under-coded cases, Wakely uses RSO algorithms to examine all the relevant data:
- Historic data and chronic conditions profile of members
- Pharmacy utilization
- Diagnosis data (as some conditions are highly co-morbid)
- Procedure codes that indicate an underlying condition
Then we give the results to your organization, which include:
- Under-coded conditions
- The reason(s) those conditions have been identified (e.g., due to consumption of a drug that indicates a particular condition)
- Expected revenue increase after coding the condition
Reports can be customized on request, and outputs can be customized to work with your organization’s reporting systems.