Risk Score Opportunities (RSO)

Wakely 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 for 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 & 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 insight on not only the members that are potential under-coded, but also providers and provider groups/clinics that might have a higher proportion of under-coded cases. Wakely RSO is designed to not be cumbersome, and works off of a fairly basic data request that our clients find easy to put together for periodic reports.

The output shows not only the under-coded conditions, but the user can drill-down to 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 aid efforts towards 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 prioritize the cases that pass a confidence threshold appear in the final exhibits. 

Our Expertise

Wakely has some of the deepest and most recognized risk adjustment expertise in the nation. From projects like the Wakely National Risk Adjustment Reporting (WNRAR), RAPID and Wakely Risk Insight - we have a unique, extremely broad and detailed perspective on the most intricate workings of risk adjustment programs.  

Next Step

We would be happy to set up a 30-minute meeting in which our experts will discuss our process with your team and show you a sample report. To schedule, please contact Products@Wakely.com.