CMS Risk Management

Risk Calculations

Data Engineering

CMS Risk Management


Managing the risk profile of your patient population is too difficult if you cannot anticipate your Risk Adjustment Factor score given by CMS. We can build an easy to use on demand calculator. Manage better.

Business Challenge

The Centers for Medicare & Medicaid Services (CMS) have instituted a method for calculating risk in order to reduce discrimination by third party payers in selecting their patient population. This risk calculation is a proprietary blend of SAS based algorithms that considers an individual demographics, including diagnoses, to assign risk scores for individuals, subsets of members and the entire population. The higher risk value results in a larger reimbursement.

The submission of this data is error-prone and requires accurate analysis of conditions in the current year and past. It leads to faulty submissions with inaccurate diagnosis codes leading to less than optimal reimbursement for companies. Companies with limited staff and compute resources cannot readily anticipate the results of the submission process.

Business Solution

Full 360 has developed a core solution that is tailored to our clients’ existing operating procedures, filling a service gap to mid-size healthcare payers by predicting reimbursement rates based on more accurate calculations as compared to “best effort submissions”. We will improve the service model by providing a standardized data process, and allow the customer to scale based on demand. If the submission is done only twice a year, the cloud infrastructure could be scaled to process the data at that time. Customers can also have reimbursement calculations provided on-demand.

Customer Outcomes

  • Full HIPAA Compliance
  • Ease of Use
  • Improved Data Integrity
  • Improved Backup & DR
  • Improved System Transparency
  • Historical Patient Record Continuity

Timelines & Costs

The Full 360 team can create a preliminary design and build a proof of concept in under six weeks for most projects. Depending on the migration strategy chosen, Full 360 will provide a full project roadmap. Following a solid assessment and meeting of key stakeholders and SMEs, the team can generally move very quickly based upon prior experience. Known areas of complexity are costed via a Fibonacci scale. The customer may choose onshore or offshore resources.

Customers We Serve

  • Healthcare & Insurance providers with Medicare or Medicaid reimbursements.
  • Customers with limited IT staff and/or compute power.
  • Customers looking to improve cash flow projections.
  • Customers looking for statistical insight on patients & patient records
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