Meet the value-based repayment needs of organizations

Value-based programs reimburse providers based on providing high-quality care to their patients rather than the quantity of care provided (fee-for-service). Since Medicare Advantage (MA) enrollment has increased 10% per year for the past two years, value-based reimbursement within your organization may also experience a slight increase. In 2021, more than 26 million people were enrolled in Medicare Advantage plans (43% of the total Medicare population) and accounted for $343 billion (or 46%) of total federal Medicare spending. Preparing your organization to help manage this growth is essential to providing ongoing high quality care to your patients and receiving accurate reimbursement.

Accurate, specific, and consistent International Classification of Diseases (ICD-10-CM) diagnosis code entry and submission by treating providers at the time of the consultation visit drives the Hierarchical Condition Category (HCC) model centered on the patient. All current and/or chronic active conditions included in the HCC models will need to be assessed, managed and reclaimed year after year. Under-reporting conditions can result in lost revenue, while inaccurate over-reporting can pose a compliance risk to your organization.

HCC diagnoses are the metaphorical hidden “suitcase” that your patients bring with them to every visit to your organization. They are contained in lists of problems and medications as well as symptoms that may be related to active or chronic conditions managed encounter after encounter – year after year – by your providers. They must capture this information accurately and consistently throughout the year and in subsequent years in their clinical documentation and coding practices. Ensuring your providers are performing these activities with accuracy and compliance is critical to maintaining quality data across your managed care population.

The keys to a successful risk adjustment program? Your people working in tandem with strong process powered by innovative and measurable Technology and reports that help capture these chronic conditions.

Do you currently have the people, processes, and technology to manage risk adjustment coding in your organization?

People: The need for specialized and certified talent

Our PwC team can help you assess, design and implement risk-based coding and documentation programs to meet your organization’s value-based reimbursement (VBR) needs. PwC’s risk adjustment coders and nurses assist clients in a variety of settings with the development of compliance-based risk adjustment coding and documentation programs. From initial design, redesign and implementation in your organization, we have developed programs from the ground up across healthcare systems to help bridge the gap between patients, providers and data in your business and the patient population.

Our PwC HCC coding and documentation team can help educate and train your in-house coding team and have assisted with the onboarding and development of CRC coder staff to get started. And if you have resource constraints, the PwC VBO (virtual business office) The team can recruit and help identify accredited risk adjustment coding and documentation talent to meet your needs. Our risk adjustment coders and clinicians will onboard and train your team on industry standard leading practices and compliant risk adjustment guidance. We will also train your team on how to identify, prioritize and provide vendor clarification opportunities.

Robust processes: if you don’t plan, you plan to fail

PwC’s empowered risk adjustment professionals can help your organization develop robust risk adjustment workflow processes, policies and procedures, clarification templates, key performance indicators/dashboards and enterprise reports and controls to help you achieve your program goals.

Our risk adjustment team performs ongoing compliance assessments to monitor your vendor’s coding quality assessment process and provides a quality and compliance review mechanism and educational strategies for vendors . Using the people, process and technology transformation approach, our team has been supporting healthcare organizations for over a decade helping them manage their risk adjustment populations and promote compliance while helping to increase HCC uptake rates.


We can help you design and build a solution that integrates with your electronic medical record (EMR) and reimbursement systems to help you accurately and compliantly capture HCCs. By leveraging your revenue cycle reports and third-party technology applications to automate processes, we can help you create VBR reports, including a robust pre-visit vendor coding and clarification process (prospective), a post-visit vendor coding and clarification process (retrospective), and established key performance metrics (coder and vendor performance metrics/dashboards).

In retrospect, we offer a coding compliance software solution, called CLEVER, that can help your organization identify high-risk HCCs in your Medicare Advantage and commercial inpatient populations.

Our CLEVER The inpatient tool has helped many of our customers in the market for 30 years. It can identify many risk-adjusting conditions by flagging a diagnostic code if it is an HCC or a case where coding and documentation may be at risk. Coders can then review, ensure any codes or cases are confirmed on file, and get an overall picture of that patient during the encounter. Our SMART tool has over 600 indicators that identify current conditions, and users can customize and create their own indicators to identify coding and documentation opportunities and validate before billing.

Improving Healthcare Experiences

While the healthcare marketplace is disrupted for patients, providers and payers, that’s not necessarily a bad thing. A human-led, technology-enabled risk adjustment program can help improve the patient experience. The drive to better manage data and processes is driving training efforts to streamline documentation and compliance.

Improved document management and accurate coding, effective strategic reviews and VBR are improvements we can all support. And some of the keys to a successful risk adjustment program that help bring about those improvements are skilled people, strong processes, and the right technology.

SMART can help you identify risk adjustment conditions and automate your revenue cycle workflows. We strive to understand their people, process and technology challenges and help them recommend innovative and appropriate solutions.

Learn more and contact our team.

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