How Charta's Smart Scan drives superior vendor performance

Medicare Advantage organizations have entered a new era of risk adjustment strategy. Advances in technology and changes to policy make it easier and increasingly important to evaluate vendor performance aggressively, against metrics for both HCC capture and RAF defensibility. 

Here’s how strategies have changed: 

Why plans are changing their coding validation strategies 

For the first 25 years of the program’s existence, payers offering Medicare Advantage plans took steps to maximize reimbursements by using every available tool and service to uncover evidence for additional HCC codes and add them to the patient’s RAF score. They devoted less attention to removing historical HCC codes and those that documentation did not adequately support. 

This orientation resulted not from greed, but from the original design of the program and its oversight mechanisms. Nevertheless, the result was an era of windfall profits for MAOs and larger-than-expected outlays from CMS generated by higher RAF scores than what program actuaries had predicted. 

Over time, as plans found increasingly efficient processes and novel technologies for coding more aggressively, the Medicare Advantage program (Medicare Part C) began to cost more than traditional Medicare (Parts A and B). Under pressure from successive administrations to bring down costs for Uncle Sam, the Centers for Medicare and Medicaid (CMS) began undertaking a series of reforms to shift health plans’ orientation from RAF accretion to RAF accuracy: after giving the industry advance notice in 2023, CMS finalized policies that ended the process of coding from charts not linked to face-to-face encounters. The agency also expanded its RADV audit program from a targeted review of plans to a universal audit of all 500+ contracts.

For Medicare Advantage organizations, these changes have shifted priorities for vendor selection and performance evaluation. For years, the crucial metrics revolved around two core metrics:

1. RAF capture: Did the vendor deliver value by finding missed diagnoses? 
2. RAF accuracy: Were incremental codes the vendor identified accurate at least 95% of the time? 

Today, these two questions are no longer enough. With CMS expanding RADV audits and tightening validation requirements and margins narrowing under the shift to V28, plans leading the way in risk adjustment are shifting from incremental coding accuracy to holistic RAF accuracy. In addition, as AI technologies make it easier to detect incremental coding opportunities, plans aren’t just comparing vendor ROI: They’re also leveraging QA solutions to measure how much their vendors are leaving on the table.

The questions risk adjustment leaders have when they evaluate vendors have shifted: 

1. RAF capture: How much value escaped the vendor? 
2. RAF accuracy:  Is the vendor accurately and reliably identifying unsupported codes in addition to capturing new incremental codes?

Leading teams are using the answers to these questions to rotate underperforming vendors out of their engagements.

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Smart Scan for vendor performance evaluation 

Vendor contracts are long. But to succeed in the current MA landscape, plans need to make sure vendor performance evaluation cycles are short and frequent. 

AI allows teams that are embracing AI efficiencies for risk adjustment to conduct QA on an outsourced vendor coding assignment immediately after it’s complete. 

Charta’s Smart Scan is helping teams conduct this sort of rapid review. Smart Scan can ingest charts, parse them by date of service, and identify every chart segment that contains high-strength evidence for an incremental HCC code. In addition, Smart Scan flags any incremental codes that lack sufficient evidence or that aren’t linked to a face-to-face encounter.

Risk adjustment can use this information to QA their vendor’s work before allocating another batch of charts, as well as to close any gaps Smart Scan uncovers. 

Smart Scan ensures maximum RAF capture while remaining RADV defensible—all within days of delivery. 

Transform your risk adjustment program from a high-stakes revenue recovery operation into a defensible intelligence engine for RAF accuracy: Talk to our team today about implementing Smart Scan to rate your vendors, maximize ROI, and ensure defensible coding before your September submission.