Risk Adjustment

Bringing Retrospective Risk into Full Focus

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 caring for your members’ care.

Our risk adjustment solutions help you effectively manage your risk adjustment program by facilitating risk score accuracy and planning for the future with more precision.

Specializing in serving regional and community-based health plans, our field-based team supports health plans to retrieve medical records, review clinical content, and ensure accurate coding of your members’ medical conditions. Our subject matter experts have over 40 combined years of experience leading risk adjustment strategies. We ensure your success through our NEAT approach:

  • NIMBLE. We help you manage data, resolve errors and provide support throughout the submissions process
  • EFFICIENT. Offering the time and attention of our subject matter experts, we proactively help you avoid common inefficiencies and realize revenue faster. Our team helps find missing data and facilitate remediation of under-reported risk scores
  • ACCURATE. Our industry leading code capture and accuracy rate ensures proper documentation
  • TRANSPARENT. We provide web-enabled timely and purposeful reporting reflecting the current status of your projects and forecasted results
chart retrieval rates at 18 weeks
data submission accuracy
coding accuracy
chart Revenue

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.

Advanced Analytics and Targeting
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.

Risk Adjustment Payment Forecast and Reconciliation
Based on your claims data, we create the extracts you use to determine premiums. We also leverage that 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.

Chart Retrieval, Review, and Coding
By leveraging a combination of chart-targeting analytics and prioritization, we maximize chart retrieval success rates to uncover new and incremental Hierarchical Conditions Categories (HCCs). To automate and 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.

Encounter and Claim Data Submission
We work with a variety of data formats to help you complete and submit your RAPS, 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.

RADV Audit Support
As an existing client, 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, assistingwith any rebuttals.

Risk Adjustment Advisory Services
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 developed to meet plan-specific objectives

Real-time HCC Reporting and Analysis
Our reporting platform is updated daily and available 24/7 to provide you with the latest real-time information- from activity reports and HCC identification tallies to risk improvement outcomes and financial forecasts. 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.

In Person and Virtual In-Home Assessments
As an augmentation of our risk adjustment services, we offer a comprehensive in-home assessment (IHA), facilitated by licensed Advanced Practice Providers. 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.




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.



code & report

Code and Report

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.




consult & support

Consult and Support

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 Solutions?
  • 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

Let’s get started. Fill out the form and we will be in touch with you.