Understand the panel's risk: which conditions are documented, what they score, and how your prevalence compares with the national Medicare Advantage rate, condition by condition.
What the panel is worth, what is missing, and what an audit would find.
Risk IQ is the largest module and the one that carries the money. It scores the panel under CMS-HCC V28, ranks the gaps by what they are worth, reconciles the financial position, sends supplemental files to payers, and audits your documentation before anyone else does.
What it is for
What Risk IQ does
Close the gaps: what has not been re-documented this year, what it is worth in RAF, and the evidence behind each suspect, with a one-click path into the Work List.
See the financial position: a ten-section profit and loss that mirrors the payer report, with medical loss ratio and funded loss ratio kept deliberately distinct.
Audit yourself first: draw and lock a sample, route review through work lists, record findings, and extrapolate with a stated confidence interval.
The screens
The screens, in the order you would use them
- 1
HCC Explorer
The panel's documented clinical picture: burden, disease groups, comorbidity pairs, a full HCC catalog, and a benchmark of your prevalence against the national rate. Type a condition in your own words to find its category.
- 2
RAF Gap Analysis
Gaps by status (new, not revalidated, suspect at high, medium, and low confidence), ranked by RAF value rather than count, with the evidence and its source behind each one. View by member, provider, or location. Bulk-add to the Work List.
- 3
Financial Summary
Premium revenue with Part A, B, and D components, projected risk adjustment, medical claims with an incurred-but-not-reported estimate, capitation, pharmacy, reinsurance, total cost, and net surplus or deficit. Per-member-per-month throughout.
- 4
ASM Submissions
Build, validate, approve, and send supplemental diagnosis files to a payer in the Verscend 2.2.9 and RA ASM 4.1 formats, with findings grouped by reason and tracking through receipt or rejection.
- 5
Audits and Templates
Draw and lock a sample, route review through work lists, record findings, and produce a stratified extrapolation with a 90% confidence interval. Headline figures show the conservative lower bound. Templates modeled on OIG protocols cover high-risk diagnoses, telehealth, and opioids.
Honest numbers
What the figures count
Every figure on every screen has a definition behind it. These are the ones this module runs on.
- Open HCC Gaps
- Conditions awaiting re-documentation this year. It counts conditions, not people, so it routinely runs several times the member count.
- Recapture Rate
- Prior-year HCCs re-documented and submitted this year, divided by those eligible for recapture. It resets every January 1 and climbs on its own as claims land, so it is read beside RAF Impact.
- Current RAF and RAF Impact
- The whole-person average across scored members, and a ceiling: what closing every still-actionable gap in time would add. A fall in RAF Impact can mean gaps closed or deadlines passed.
- Recoverable (lower bound)
- What an audit would demand. The point estimate is always larger and is never the number to quote.
What can go wrong
What this module will not let you misread
Reading the two loss ratios on one scale
Medical loss ratio and funded medical loss ratio share a numerator and differ in denominator, and each is judged against its own target. The same months can read healthy on one and at risk on the other by construction.
Quoting the audit point estimate as exposure
The demanded amount is the lower bound of the confidence interval, and it is always smaller.
Comparing a member's RAF to a gap's RAF
One scores a whole person, the other a single condition. Both print to three decimals, which is exactly what makes them look comparable.
Where the data comes from
Payer risk files, claims and coded history, financial statements, and the CMS-HCC model itself, with full V28 scoring (demographics, condition mapping, hierarchies, interactions, normalization) and the V24 crosswalk. Suspects come from multi-signal clinical rules, each with its citation, its evidence card, and a measured precision that retires low-value rules.
How Alara Healthcare uses it
Alara Healthcare's risk adjustment service runs on this module: documentation and coding review, supplemental submissions, RADV readiness, and provider education, with every finding routed through the Work List so nothing found in an analysis stays in an analysis.
Risk Adjustment servicesQuestions people actually ask
Risk IQ questions
We have far fewer members than open HCC gaps. That can't be right, can it?
It can, and it usually is. Open HCC Gaps counts conditions, not people. One member can carry several conditions awaiting re-documentation this year, so the gap count routinely runs several times the member count. For a per-person view, RAF Gap Analysis groups the same gaps by member.
Our recapture rate went up but nobody worked a single gap this week. How?
That is expected. The rate climbs on its own as claims arrive and documentation catches up, so some movement reflects data landing rather than work done. It also resets each year. To judge whether the movement is worth anything, read it beside RAF Impact, which is measured in value rather than count.
A coder's acceptance rate shows N/A instead of 0%. Is that a bug?
No. N/A means suggestions were surfaced and no provider has ruled on any of them yet, so there is nothing to be right or wrong about. A true 0% means providers did rule and accepted none. Reporting the first as the second would penalize a coder for a decision that belongs to someone else.
See Risk IQ on your own file layout.
Bring a sample payer file to the demo and we will show you where it lands, what it surfaces, and who works it.