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National RA/HCC Audit Project Case Study
Table of Contents
Table of Contents


National RA/HCC Audit Project: Unparalleled subject matter expertise and quality lead to validation success.

When a large agency sought to determine the performance and validity of risk adjustment and HCC coding across the nation, they contracted with a renowned global leader in healthcare auditing.

Over the last five years, e4health proudly worked with this respect-ed federal contractor to undertake a large HCC audit project.

The multifaceted engagement consisted of two pilot years followed by three years of second-level validation. The endgame: Delivering audit quality, accuracy, efficiency, and proper guidance on audit protocols and recommendations.

Click here to download e4health’s CDI Case Study.

The Challenge

The Hierarchical Condition Category (HCC) risk adjustment model assigns a risk score, also called the Risk Adjustment Factor or RAF score, to each eligible patient. A RAF score is calculated based on the patient’s underlying health status and demographics. Documentation is critical — a patient’s health record must support the presence of the condition as well as indicate the provider’s monitoring, assessment, and plan for the management of the condition. Simply put, the documentation and reporting must be accurate, specific, and clinically valid.

Since quality and expertise represent the pinnacle of any project’s success, our highly qualified and experienced subject matter experts were engaged by a federal auditing organization to perform a risk adjustment data validation (RADV) audit.

IQ Auditing Actions: The Value of Expert Validation

Assess RA/HCC coding accuracy; a crucial factor in determining proper reimbursement.

Focus on value-based reimbursement is necessary as traditional provider payment transitions away from fee-for-service (volume-based reimbursement).

Highlight areas of non-compliance with the current HCC/RA models and guidelines that can potentially put revenue at risk.

Advise all plans/issuers to specifically document comorbidities that affect patient care and impact medical decision making.

The Solution

IQ Strategy: Expertise Guiding Success

The e4health team put into motion a two-pronged strategy by placing IQ experts at the forefront – a collaborative duo with an unparalleled grasp of inpatient and outpatient settings. Kim Felix, RHIA, CCS led and directed the audit as Project Manager. She was assisted by Jeanie Heck, BBA, CCS, CPC, CRC, who served as the Lead Senior Auditor.

Kim’s extensive inpatient knowledge, coupled with Jeanie’s extensive outpatient knowledge, created an environment that facilitated deep scrutiny and conquered monumental obstacles. Their leadership earned respect and the endorsement of both the federal contractor and client. In fact, after the first pilot year, the contractor engaged the e4health team for the four remaining years of the contract.

IQ Education: Winning Knowledge

Knowledge is powerful, and the e4health team believes education is a game-changer. It is at the foundation of every endeavor and was evident throughout the project.

Bringing teaching experience from colleges and universities across the nation, IQ leaders shared informa-tion to improve understanding and build the knowledge base. Their insight proved two simple facts: 1) If chronic, life-long conditions are properly documented and coded, adjustments may be made to issuers’ enrollee risk scores and risk adjustment transfers. 2) e4health IQ education sessions identify pitfalls, patterns, and trends that can lead to optimized risk scores.

The Pinnacle of Success: What We Accomplished

  • Managed a large team of coders/ validators.
  • Trained staff in various roles to quickly adjust to client needs.
  • Enabled continuous retraining to accommodate and implement client requests.
  • Provided proven project management strategies and methodologies led by industry-acknowledged subject matter experts.
  • Navigated project management technology and other software to maintain efficiency.
  • Met the client and prime contractor’s demands and provided services with the highest level of expertise, professionalism, and attention to detail.
  • Possessed and shared a thorough knowledge of disease processes and coding guidelines necessary to execute a successful RADV project.
  • Audited/Validated over 50,000 records.