Five percent of MA members and 13% of Duals members rotate through a SNF; yet, SNF claims are not an allowable claims source for risk adjustment.
By comparing plan claims data and historical MDS data, PointRight can identify new diagnoses and conditions that are: (1) Present but not coded on an allowable claims (90% probability); (2) Present but not diagnosed by a physician (70% probability); and (3) Probably present but requiring a clinical assessment (50% probability). The PointRight Pulse suite of analytics services can help identify potential diagnoses based on a combination of evidence that most likely will not be found as a result of a health risk assessment alone. For example, one health plan currently using MRA vendors was able to identify $8 Million in missed risk adjustment dollars in just two of their states. The average RAF score increase of .24 RAF points is equal to approximately $2,400 per member admitted to a SNF; or $120+ per member per year.