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Effectively managing risk is a vital part of what you do. Inaccurate or incomplete documentation can result in costly penalties and lost opportunities to generate appropriate compensation for the care you provide to your members.

From performance monitoring and management to encounters, PopHealthCare is your end-to-end Risk Adjustment partner. Whether we support you as a full-service risk adjustment partner or we address a single part of your process, our holistic expertise enables us to think beyond specific areas of focus to ensure success at every touchpoint along the way.


Our comprehensive risk adjustment solutions leverage a unique combination of technology, in-depth industry expertise, and concierge-level service to help you accurately document Hierarchical Condition Categories (HCCs) and ensure you receive appropriate reimbursement to care for the members you serve.


We can help you navigate the entire risk adjustment process from chart acquisition, review, and coding, to data submission, storage, and online reporting.

Continuous and comprehensive data analytics is at the foundation of everything we do. We leverage data from a variety of sources to deliver the broadest possible view of your members’ health profiles. First, we ensure the completeness and accuracy of existing diagnoses. Then, we apply predictive analytics to identify additional HCC and quality opportunities. A thorough review is conducted each month to ensure you have the most accurate view of risk scores throughout the entire year.

By monitoring your risk adjustment management initiatives, we can help you gain greater visibility into your revenue. These services provide actuarial support for bid analysis and financial forecasting.

This solution includes:

  • Reporting at contract, plan benefit package (PBP) and medical group levels
  • Revenue forecasts for booking receivables (+/- 1-5% accuracy)
  • Restated Membership Monthly Report (MMR) reporting: recalculated risk scores and PMPM revenues
  • Medicare Bid Rate Support
  • Unique reports to meet plan-specific objectives

For Payment Forecasting and Reconciliation, we leverage your claims data to create the extracts you use to determine premiums. We also leverage this data to understand your revenue and forecast your risk adjustment revenue. We look at the risk variables that could cause your company to over- or under-perform its forecast and come up with contingency plans to handle either scenario.

From activity reports and HCC identification tallies to risk improvement outcomes and financial forecasts, our reporting platform provides you with the latest information. The ability to drill down into the details gives you a clear line of sight into program performance, empowering you to make critical decisions that have a direct impact on your outcomes.

Leveraging chart-targeting analytics and prioritization, we maximize chart retrieval success rates to uncover new and incremental Hierarchical Conditions Categories (HCCs). To accelerate this process while reducing provider friction, we use automated technologies such as Natural Language Processing (NLP) and EHR interoperability capabilities. Our field-based team of imagers and certified coders will work with you to retrieve medical records—electronic and physical charts—review clinical content and ensure your members’ medical conditions are accurately coded.

And, should you be selected for a risk adjustment data validation (RADV) audit, a dedicated project manager will walk you through the entire process. We identify the medical records that need to be acquired and work with you to submit the required documentation to CDAT, assisting with any rebuttals.

We work with a variety of data formats to help you complete and submit your EDPS, and EDGE claims data to CMS. Plus, we help you resolve and submit any data corrections or additions. Our data cleansing processes and active pursuit of supplemental data files ensure complete submission of HCCs from administrative data sources.

As an augmentation of our risk adjustment services, we offer comprehensive in-home assessments (IHAs), delivered by licensed Advanced Practice Providers from our national provider group, Emcara Health. We visit members in their homes in-person or via telehealth to document all health conditions and provide a detailed report with action plan to members, their primary care physician and the health plan. Our assessment includes clinical, behavioral and social determinants that contribute to the member’s health.

How It Works


First, we work with you to understand your strategic goals. Based on your specific needs, we customize an approach that will work best for you.


We establish data exchange requirements and work with you to get a list of providers and charts you want to include in your risk adjustment sweep season, and then determine the location and the optimal retrieval approach. Together, we develop an implementation schedule that meets all CMS compliance and submission deadlines.


We analyze data, acquire charts, and accurately update codes. Access to real-time reporting on progress and forecasted payments is available 24/7 through our web-based portal.


We offer ongoing support through a variety of scenarios, including best practices for submitting coding data to CMS, responding to government audits, as well as financial forecasting and bid consulting. We also take a close look at the data to uncover additional insights and opportunities to control costs or improve operational efficiency.

Why PopHealthCare Risk Adjustment?

  • We deliver a proprietary combination of advanced technology, concierge-level service, and expertise
  • An in-house team of risk adjustment experts with over 40 years combined experience working at large health plans supports you
  • Experienced and certified in-house coding team consistently achieves 97% coding accuracy
  • We make it easy by working with all data formats for analysis and CMS submission