Your risk scores are only as good as the documentation behind them.
HCC risk scores reset every year, so a chronic condition that is not documented and coded in the current year drops out of the risk profile even when the patient still has it. We find the gaps, support accurate recapture, and keep the documentation defensible for audit.
What is HCC risk adjustment?
CMS Hierarchical Condition Category (HCC) risk adjustment uses documented diagnoses to set the payment benchmark for a patient population. A diagnosis has to be documented and coded again in the current calendar year to count, so a chronic condition that goes unrecaptured drops out of the risk profile even though the patient still has it.
Every angle of risk adjustment, covered.
Documentation drives your benchmark. Each missed diagnosis code understates that patient's individual risk score, and across enough patients, those gaps compound into an understated risk profile for the population as a whole. These are the capabilities that keep documentation accurate at every level.
Suspect identification.
Suspect identification runs across a multi-year and longitudinal view of the beneficiary population, not a single-year snapshot. A condition documented three years ago but never recaptured since is exactly the kind of gap a single-year review misses.
Extended lookback.
An extended lookback of 14 years compared to the standard 3 gives a fuller history behind every suspected condition, so recapture decisions are based on a complete clinical picture rather than whatever happened to be coded most recently.
Recapture strategy.
A recapture strategy covers both retrospective and prospective approaches. Retrospective analysis identifies gaps in existing documentation, and that analysis leads to action that is supported prospectively, reinforcing documentation ahead of time to anticipate audit.
Risk score gap quantified.
The risk score gap is quantified at the population, plan, and provider level, so the opportunity is visible whether you are looking at the whole panel, a specific plan, or a single provider's patients.
HCC gap identification.
HCC gap identification and claims monitoring stay current as new claims arrive, rather than relying on a periodic batch review that is already out of date by the time it is delivered.
Crosswalk analysis.
Crosswalk analysis identifies acute conditions that can lead to chronic conditions, flagging that transition risk rather than treating the acute diagnosis as a one-time event.
Clinical deployment model.
The clinical deployment model integrates into existing provider workflow. Coding opportunities surface where a provider is already working, rather than asking practices to adopt a new system or change how they document care.
Population segmentation.
Population segmentation prioritizes outreach so effort goes toward the patients and conditions where closing the gap will have the most impact, rather than treating every suspect with equal urgency.
Powered by direct CMS data access and proprietary infrastructure built over years.
This work runs on infrastructure we built and maintain ourselves, not a reporting layer added on top of someone else's data feed.
Built for Medicare programs and other risk-bearing entities.
Risk adjustment accuracy matters anywhere CMS uses HCC risk scores to set a benchmark. The same infrastructure applies across programs.
Full support for MA plans.
Risk adjustment for Medicare Advantage (Part C) populations, using the same direct CMS data access and 14-year lookback methodology described above.
- Direct CMS data access covering Part C encounter data
- Same 14-year lookback and recapture methodology
- Directly relevant to RADV audit exposure, which applies specifically to MA risk adjustment
Medication-related risk visibility.
Part D claims surface medication-related risk factors that pure medical claims can miss, particularly for polypharmacy and frail populations.
- Medication-related risk visibility from Part D claims
- Useful alongside medical claims, not a replacement for them
- Supports a fuller view of complex, high-needs patients
Pairs with audit-ready coding.
Risk adjustment and audit readiness are complementary services built on the same infrastructure.
- Chart validation against claims and medical records
- Pre-audit detection and audit simulation
- Its own service line within the platform
Let's talk about your risk adjustment program.
Tell us about your population and we'll walk through what this looks like for your organization.