Risk Score Opportunities (RSO)

Wakely Risk Score Opportunities (RSO) is a set of proprietary algorithms that identify and prioritize members who are most likely to have a condition that has not been coded.  The algorithms have been separately calibrated for the commercial Affordable Care Act (ACA) market, the Medicare Advantage market, and various state Medicaid programs using CDPS or Medicaid Rx models. Clients can choose to purchase the RSO analytics for one or more of their lines of business.

Efficient and transparent analytics.

Our goal with Wakely RSO is to provide our clients with an efficient analytic service that quickly parses through data and provides useful insights on not only the members that are potentially under-coded, but also on providers and provider groups/clinics that might have a higher proportion of under-coded cases. Wakely RSO’s user-friendly design works off of a basic data request that makes it easy to put together periodic reports.

The output not only shows the under-coded conditions, but also allows the user to drill down and see why those conditions have been identified (e.g., due to consumption of a drug that is highly indicative of a particular condition). This is important for purposes of understanding the suspecting logic and to facilitate complete and accurate coding of members.

Potentially missing conditions in a benefit year are identified via a) historic data and chronic conditions profile of members, b) pharmacy utilization, c) diagnosis data, as some conditions are highly co-morbid, and d) procedure codes that indicate the presence of an underlying condition. The algorithm considers all pieces of evidence together, and only cases that pass a confidence threshold appear in the final exhibits.

Unique products and tools.

Wakely has developed these industry-leading products and tools, which empower our clients to make highly informed strategic decisions.

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Wakely Medicare Advantage Competitive Analysis Tool (WMACAT)

Allows health plans to compare Medicare Advantage benefits and market information at the national, state, and county levels, to evaluate plan design and performance.

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Wakely National Risk Adjustment Reporting (WNRAR)

Provides risk adjustment metrics from 35 states and 19 million lives.

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Wakely Plan Valuation Model (WPVM)

Supports pricing, mental health parity compliance, cost and utilization analysis and more.

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Risk Adjustment Payment & Identifying Discrepancies (RAPID)

Gets the most out of your EDGE data.

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Wakely Analytics Health Operations Optimization (WAHOO)

Helps payers and providers optimize financial performance with a complete package of services and tools.

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Wakely Affordable Care Act Competitive Analysis Tool (WACACAT)

Allows users to interactively explore market metrics.

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Wakely Risk Assessment (WRA)

Provides a transparent, open-code, high-performance risk assessment model.

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Wakely Risk Insight (WRI)

Includes two major components: The Medicare National Report (MNR) and WRI-MA. Both pinpoint drivers of profitability and compare them to national benchmark data.

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Wakely Risk Insight National Reporting Project (WRINR)

Identifies key profitability drivers for the individual and small group markets.

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Wakely Medicare Repricing Analysis Tool (WMRAT)

Aids the comparison of payment rates across multiple lines of business, categories of service, geographic locations, and providers.

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Wakely ACA Database (WACA)

Contains the most robust and detailed ACA data available in the industry.

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Risk Adjustment Data Integrity Analysis & Lineage (RADIAL)

Compares multiple data sources to provide transparency in risk score differences.

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Risk Adjusted Payments & Identifying Discrepancies for Medicare Advantage Plans (RAPID-M)

Helps plans optimize risk scores by identifying RAPS and EDS inconsistencies

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