HCC REVENUE
MANAGEMENT SERVICE
The comprehensive, transparent approach to Risk Adjustment
DST’s HCC Revenue Management Service:
End-to-end support
DST’s HCC Revenue Management Service accurately documents
member conditions, identifies gaps in care and helps you obtain
proper reimbursement. We cover every aspect of risk adjustment,
from identifying suspected HCCs, to validating and substantiating
these, to comprehensive coding, abstraction and submission of
data. We serve Medicare Advantage and ACA plans.
Our end-to-end approach frees you to focus on member care
while we work to ensure that you are properly reimbursed for the
risk you take in covering members. We provide:
Healthcare has changed, and many of these changes profoundly
affect payers’ bottom lines. One example is the dramatic growth
of the risk adjusted payment model. Since 2007, Medicare
Advantage plans have been reimbursed by the federal
government for the risk burden of members. With passage of the
Affordable Care Act (ACA), many other payers now receive risk
adjusted payments.
Payments are based on risk scores, which are derived from
hierarchical condition categories (HCCs). HCCs are intended to
reflect members’ diagnoses. Although accurate HCCs and risk
scores are crucial to payers’ financial well-being, many payers
lack the technologies, streamlined business processes and
experienced coding staff necessary to fully document risk. Year
over year, these organizations stand to lose out on millions of
dollars in revenue.
DST Health Solutions understands the importance of these
changes and is focused on helping payers thrive as the business
model continues to evolve.
• Powerful clinical algorithms that identify potential
risk-score discrepancies and stratify “suspect” members
and providers
• Detailed what-if planning scenarios that help you
understand which suspect members will have the greatest
financial impact; we’ll also help you understand the impact
of various “chase” strategies
• Quality-focused, full-time coders who undergo continual
training and extensive monitoring
• Comprehensive coding that substantiates members’ medical
conditions, clinical diagnoses and HCCs
• Cost-conscious operations that incorporate your budgetary
guidelines, business rules and provider-engagement rules
into the chart retrieval and abstraction processes
• Extensive experience submitting required data to the
Department of Health and Human Services (for ACA plans)
and Centers for Medicare and Medicaid Services (for
Medicare Advantage plans).
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6. Submitting the required data. DST can submit required data on
your behalf via the Edge server for ACA plans or via RAPS/EDPS
files for Medicare Advantage plans.
Keep your focus on member care
DST’s HCC Revenue Management Service takes
care of the details of risk adjustment to ensure
risk-score accuracy so you can focus on providing
the right care for your members and receive
accurate compensation for your true risk burden.
Additional services from the HCC experts at DST
Risk Adjustment Data Validation (RADV) Services: DST’s
transparent, collaborative process helps you through every stage
of a RADV audit. Our chart retrieval services gather needed
records, and our certified coders review these, helping you
validate members’ documented risk scores.
Six steps to proper reimbursement
DST’s HCC Revenue Management Service comprises
six key steps:
Mock RADV Audit: We prepare you for a RADV audit, simulating
the audit and identifying areas for improvement.
1. Identifying suspected HCCs through sophisticated clinical
based algorithms. Advanced analytics tools enable us to rapidly
identify risk-score discrepancies and stratify suspect HCCs
with respect to financial impact and probability of successful
validation, along with HCC category and other criteria.
2. Conducting “what-if” analyses to help you identify the best
risk adjustment strategy for your budget. We provide insights
that help you determine which clinical algorithms to use, which
suspects to pursue, how your business rules will affect the
bottom line and more.
3. Retrieving medical charts. Our professional chart retrieval
services cover all 50 states and can obtain needed medical
records through conventional requests, EHR transfers and
site visits.
4. Abstracting members’ charts. DST’s full-time staff of
experienced, certified coders substantiates unrecorded medical
conditions, missing diagnoses and undocumented or incorrectly
documented HCCs.
5. Keeping you informed every step of the way. We deliver regular
reports on project status, investigations of HCC suspects and the
financial impact of our work.
Risk Adjustment Audit: DST reviews your member records,
gauging accuracy and consistency.
Whether you operate an ACA or Medicare Advantage plan, DST’s
HCC Revenue Management team can accurately document
member conditions so you can focus on ensuring that members
receive appropriate care while you receive proper payment for
the risk you’ve assumed.
About DST Health Solutions
DST Health Solutions delivers healthcare technology and service
solutions that enable clients to thrive in a complex, rapidly
evolving market. Our portfolio, which includes enterprise payer
platforms, population health analytics, care management, and
business process outsourcing solutions, is designed to help
clients successfully manage their most important business
functions while facilitating strategic and financial growth. We
assist commercial, individual and government-sponsored health
plans, and healthcare providers in achieving the goal of affording
the best possible care to their members and patients. DST Health
Solutions is a wholly owned subsidiary of DST Systems Inc.
DST Systems, Inc. (DST) has provided the information in this Product Sheet for general informational purposes only, has a right to alter it at any time, and does not guarantee its timeliness, accuracy or completeness. All obligations of DST with
respect to its systems and services are described solely in written agreements between DST and its customers. This document does not constitute any express or implied representation or warranty by DST, or any amendment, interpretation or other
modification of any agreement between DST and any party. In no event shall DST or its suppliers be liable for any damages whatsoever including direct, indirect, incidental, consequential, loss of business profits or special damages, even if DST or its
suppliers have been advised of the possibility of such damages.
© 2015 DST Systems, Inc.
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Learn More
DST Health Solutions
800.272.4799 | Marketingdsths@dsthealthsolutions.com | visit www.dsthealthsolutions.com