Risk Score Opportunities (RSO)
Wakely Risk Score Opportunities (RSO) is a set of proprietary algorithms that identify and prioritize members who are most likely to have a condition that has not been coded. The algorithms have been separately calibrated for the commercial Affordable Care Act (ACA) market, the Medicare Advantage market, and various state Medicaid programs using CDPS or Medicaid Rx models. Clients can choose to purchase the RSO analytics for one or more of their lines of business.
Efficient and transparent analytics.
Our goal with Wakely RSO is to provide our clients with an efficient analytic service that quickly parses through data and provides useful insights on not only the members that are potentially under-coded, but also on providers and provider groups/clinics that might have a higher proportion of under-coded cases. Wakely RSO’s user-friendly design works off of a basic data request that makes it easy to put together periodic reports.
The output not only shows the under-coded conditions, but also allows the user to drill down and see why those conditions have been identified (e.g., due to consumption of a drug that is highly indicative of a particular condition). This is important for purposes of understanding the suspecting logic and to facilitate complete and accurate coding of members.
Potentially missing conditions in a benefit year are identified via a) historic data and chronic conditions profile of members, b) pharmacy utilization, c) diagnosis data, as some conditions are highly co-morbid, and d) procedure codes that indicate the presence of an underlying condition. The algorithm considers all pieces of evidence together, and only cases that pass a confidence threshold appear in the final exhibits.
