Providing insight and transparency into your risk adjustment initiatives

Analytic and Forecasting Services

Financial & Risk Adjustment Advisory Services 

PopHealthCare’s Financial and Risk Adjustment Advisory Services offers revenue and ROI visibility through the monitoring of a health plan’s risk adjustment management initiatives. These services provide actuarial support for bid analysis and financial forecasting.


Our solution includes:

  • Reporting at contract, plan benefit package 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, which includes:

o   Monitoring ongoing funds and RAF impact of prospective assessments

o   Estimating potential score improvement for a prospective contract for a client who contracts with nursing homes

o   Evaluating the value of initiatives under different attribution order scenarios

HCC & Quality Gap Targeting & Prioritization Analytics

The foundation of our programs is in continuous, comprehensive data analytics. Before predictive analytics are applied to identify HCC and Quality opportunities, our experienced analytics team digs deep into the data to maximize the completeness and accuracy of the existing diagnosis set. Propriety filters and algorithms are applied to identify potential compliance concerns, providing the plan with diagnoses that are unlikely to be supported by clinical documentation required in an audit. This careful review is done on a monthly basis, providing the plan the most accurate view of risk scores throughout the entire year.

PopHealthCare’s approach to predictive analytics leverages an expansive variety of data sources to deliver the broadest possible view of a member’s health profile. Under constant review and improvement, our analytics are designed to capture the best-available, most timely data sources that have predictive value. 


HCC Reporting, Analysis & Data Visualization 

Our dynamic real-time data visualizer and reporting tool provides real-time program status reporting inclusive of activity reports, HCC identification tallies, risk improvement outcomes and financial forecasts. Our reporting system offers easy slice and dice functionality, aggregations and drill-downs into results, and the ability to view program outcomes by intervention types, by plan, by geography or other parameters that are of high priority to the plan. 

The reporting platform also offers a deeper view on condition-specific program results, through click-through to any level of data and the ability to filter results real-time by:

  • Geographic locations
  • Age bands
  • Condition(s)
  • H Contract and PBP
  • Pre-existing co-morbidities
  • In-Office / In-Home
  • Other factors determined in collaboration with the plan

The ability to create real-time data visualization provides health plans actionable information for understanding the value and benefits of the program. The tools enable health plans to make quick, critical decisions that will impact outcomes by measuring and tracking program performance in real time.

RAPS / EDPS / EDGE Data Enrichment, File Prep & Reconciliation Services

RiskSight includes end-to-end data management and RAPS / EDPS / EDGE file creation, submission and reconciliation as follows:

  • Monthly creation and submission of RAPS files (and EDPS when requested)
  • Inclusion of RAPS data created as a result of prospective in-home assessments and retrospective chart collection
  • Coordination of claims data and submission of applicable test files and parallel processing files to CMS
  • Comparison of results between RAPS and EDPS submissions in order to quantify risk associated with the EDPS environment
  • Error resolution support and root cause analysis with the appropriate health plan teams

Our process evaluates data that comes in to our system before going to production. We also have back-end reporting for every file produced that gives us information on what was created in the file and what did not make it through the filter, and why. Examples of excluded claims include those with inappropriate procedure codes, bad specialty provider codes, and duplicate HCCs. We submit the results to the health plan before RAPS files are submitted CMS. 

Our solutions incorporate a high degree of pre- and post-editing of client data to minimize errors associated with the submission process. PopHealthCare’s data cleansing processes and active pursuit of supplemental data files ensure complete submission of HCCs from administrative data sources and adds tremendous value to our clients.  

Getting Started

Contact us today for a free consultation and analysis of your data.