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RAAPID Team on Risk Adjustment and the Best Practices to Avoid Legal Complication

RAAPID Team on Risk Adjustment and the Best Practices to Avoid Legal Complication

The team highlights the potential legal penalties associated with an incorrect risk score and provides insight as to how to avoid such complications.

LOUISVILLE, Ky., April 12, 2022 ( – The team behind RAAPID, the world’s first personalized AI assistant for risk capture, is actively advising clients on risk adjustment and providing best practice resources to avoid legal complications.

A proper, legally viable, and tech-driven risk score calculation is pivotal for healthcare organizations, insurance providers, coders, and, of course, patients. The risk score derives the total amount of insurance premium to be born or paid by both insurance companies and patients for Medicare.

If calculated incorrectly, legal penalties may arise for providers as a result. The entire ecosystem of risk adjustment or premium calculation gets disturbed when scores are calculated incorrectly. This can also have a negative impact on ROI (return on investment) for healthcare organizations, coding companies, and insurance companies.

It is projected that the number of retrospective chart reviews by the Office of Inspector General (OIG) and Center for Medicare & Medicaid Services (CMS) will be increasing in 2022. RAAPID’s leadership team has stressed the importance of accuracy within these reports, as the aforementioned agencies will be reviewing the ways in which organizations conduct said medical record reviews after treatment is provided, as well as whether the codes are linked to actual encounters.

The adoption of telemedicine was accelerated by the COVID-19 outbreak of 2020. Healthcare institutions and healthcare providers can expect an increase in the number of investigations into in-home assessments, per RAAPID. Past investigations have covered issues such as assessments that were completed with allegations that the provider was absent or conducted an unrealistically high number of assessments during a given day. Other investigations evaluated the effectiveness of diagnoses made in a home setting, reviewed the level of training given to staff members, and examined the equipment used for said meetings. In terms of best practice, healthcare institutions and insurance providers should ensure that all aspects of telehealth consultations are up to par in order to avoid legal penalties.

Healthcare and insurance providers must also be aware of how their own compliance activities may be held against them regarding overpayment issues. The Social Security Act requires these providers to return overpayments that are identified within 60 days; if one of these entities was to fail to initiate appropriate remediation through deletes, fail to submit deletes in time, or fail to go far enough in their internal investigation, they may be liable for legal penalty.

The Center for Medicare & Medicaid Services (CMS) appeal of a legal decision struck down a rule that required Medicare Advantage insurers to report and return overpayments to the federal government. The preamble of said rule included the requirement for organizations to identify, report and return any overpayment “after reconciliation” within 60 days after the date on which the overpayment was identified. However, healthcare and insurance providers should be wary of the difficulties that come with identifying the root cause of a problem, solving it, and issuing a deleted file within 60 days. According to RAAPID’s team, this turnaround time has proven to be troublesome for many providers.

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We are reimagining risk adjustment for healthcare, insurance, and technology businesses.

With a comprehensive workforce of over 500 members who are industry veterans, based out of India and the U.S., RAAPID’s pedigree is built upon Trust, Tech Competence, Stability, and Tech Innovation.

Healthcare doesn’t stop at 5 o’clock. Neither do we. We know this because it has been close to a decade now. We want your organization to be successful and have accurate reports when you need them. That’s why we make patient service a priority and ensure our technology stays up-to-date to avoid errors entirely.

Every Organization Is Unique and Deserves Personalized AI Solution, and RAAPID is a completely integrated, AI-powered disease understanding and extracting engine that operates on any patient data—including the free text, and unstructured content—to capture the complete risk of the patients.

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Source: RAAPID