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Prospective Risk Adjustment solution

Accurately document disease burden and close care gaps

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Without insights into the disease burden of their members, health plans cannot intervene and coordinate adequate care, and untreated conditions can lead to increased reliance on avoidable high-cost care like emergency room visits and inpatient stays. Additionally, deferred healthcare utilization and a coinciding drop in claims could lower risk-related payments.

Cotiviti’s Prospective Risk Adjustment solution address these challenges by helping health plans gain insights into their member’s risk profile, accurately document disease burden to secure risk-related reimbursement, close gaps in case, and enable proactive interventions.

  • Add incremental value of $1,400 on average per member annually
  • Ensure appropriate risk-adjusted payments with accurate documentation and coding of member conditions
  • Achieve ROI of 4–7x based on increased risk adjustment factor (RAF) from conditions that map to new or higher-revenue HCCs