With the passing of the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003, the Centers for Medicare and Medicaid Services (CMS) initiated the formal implementation of a fully risk-adjusted capitation reimbursement model.  As a result, all Medicare Advantage (MA) plans and Prescription Drug (MAPD and PD) plans are financially dependent upon the specific documentation of each individual patient’s diagnoses and comorbid conditions as classified within the highly specific CMS Hierarchical Condition Category (HCC) system. 

With Medicare serving as a precedent, many additional risk adjustment initiatives have been increasingly following suit. The Medicaid and commercial landscape is rapidly adopting a risk adjusted reimbursement model in nature or entirety. With this, accurately assessing and representing the comprehensive encounter, diagnostic, procedural, and pharmaceutical characteristics of enrollees has become paramount to those plans dependent on appropriate reimbursement. Regardless of the underlying risk adjustment factor determinant toolset – whether HCC, CRG, ACG, CDPS, DCGs, or other model – the requirement of accurate assessment, improvement, and reporting of factors that drive risk score calculation is critical. Failure to do so has both significant quality of care implications and critical financial ramifications.

To aid its Medicare Advantage, managed Medicaid, and other risk adjustment-based healthcare clients, MedAssurant delivers a suite of “end-to-end” Capitation Risk Adjustment (CARA™ and CARA-Rx™) solutions designed to identify, analyze, pursue, and document a plan’s complete risk adjustment dataset not otherwise properly or fully captured by primary claims systems. The CARA™ solutions demonstrate impressive return on investment for both financial and quality initiatives. Whether to maximize prospective risk factor identification for bid accuracy or optimize future reimbursement rates, or to ensure that full reimbursement is recaptured for past periods in final reconciliation processes, CARA™ assists each client in efficiently and accurately implementing a system to optimally identify and capture the broad array of healthcare data and characteristics of its enrollees enabling superior quality improvement initiatives as well as full and accurate reimbursement from CMS, states, and other payment agencies.