Solutions · Risk Adjustment & HCC

Risk Adjustment & HCC

Every Diagnosis Captured. Every Risk Score Accurate. Every Dollar Accounted For.

Risk adjustment and HCC coding built for both providers and PAYERS - accurate, compliant, and audit-ready.

Risk scores that miss real patient complexity miss reimbursement your care has actually earned, while escalating operational friction and exposing the system to severe audit risk. Valerion Health delivers end-to-end HCC coding and risk adjustment solutions purpose-built for PAYERS and providers - eliminating compliance gaps, securing the full reimbursement your patient complexity demands under value-based care, and defending the bottom line.

Talk to a Risk Adjustment Specialist See how we help
CMS-HCCHCCRADVICD-10-CMRAF score
Sample risk capture
Audit · ready
  • HCCE11.22Diabetes with CKD - captured and specific
  • HCCN18.4CKD stage 4, re-documented this year
  • HCCI50.32Chronic diastolic heart failure
  • RAFSUPPEvery diagnosis supported in the record
Captured · Coded · Defensible
Where Risk Adjustment Sits

The step that turns a diagnosis into a risk score.

Documentation records the condition. Capture decides whether it counts. Everything after - payment, benchmarking, audit - reads from what was captured.

  1. 01
    Provider documentation

    Conditions recorded in the chart

  2. You are here
    Diagnosis & HCC capture

    Every relevant condition identified

  3. 03
    Risk score calculation

    RAF built from submitted diagnoses

  4. 04
    Risk-adjusted payment

    Value-based reimbursement is set

  5. 05
    RADV / payer audit

    The record gets re-checked

From one chart, a chronic condition can only end up in three places.

Target
Captured and supported

Coded to specificity, documented, defensible on audit.

Cost
Captured but unsupported

Recouped at RADV, with exposure attached.

Cost
Never captured at all

The risk score understates the patient. Revenue never arrives.

Why It Matters

Under risk-adjusted models, coding accuracy is what your reimbursement is built on.

When it comes to value-based care, risk scores are the foundation of revenue. When coding is imprecise, the financial and compliance upshot is immediate.

One under-coded chronic condition
a risk score that understates real patient acuity
One missed HCC capture opportunity
reimbursement left on the table under value-based contracts
One unsupported diagnosis
exposure under CMS-HCC or RADV audit
One inconsistent coding pattern across a provider panel
risk scores that don’t hold up to scrutiny

Under risk-adjusted and value-based models, coding accuracy isn't just about compliance - it's what your reimbursement is actually built on.

Where It Breaks Down

Why risk adjustment coding often misses the mark.

Traditional risk adjustment coding frameworks that operate in silos can wilt under the complexity and nuance of modern healthcare. Inconsistencies between documentation, HCC coding, and medical record retrieval can directly impair the value of audit outcomes and long-term performance.

Documentation doesn’t support RAF scores

Conditions are treated but never captured with the specificity a risk score requires.

HCC coding doesn’t reflect audit standards

Codes assigned without the rigor CMS-HCC and RADV review demand.

Medical record retrieval doesn’t measure up

Retrieval processes that can’t meet CMS RADV audit demands when it counts.

Time to connect risk with reality.

Valerion Health's risk adjustment coding and HCC coding services connect the dots between documentation, coding, and analytics to create a foresight-rich, gap-free, audit-ready, and repeatable revenue model.

  • Address every workflow - prospective, concurrent, retrospective
  • Build real-time visibility into risk
  • Ensure revenue predictability
Our Approach

How Valerion Health Helps

Valerion Health bridges the gap between clinical documentation and financial reality. Our end-to-end risk adjustment and HCC coding solutions - designed for both providers and PAYERS - ensure every documented condition is comprehensively captured, coded, and defensible.

Risk Adjustment Coding - Accurate, compliant coding aligned to CMS-HCC and payer-specific risk adjustment models.

HCC Coding - Complete, well-supported HCC capture across chronic and complex conditions, coded to the highest specificity the documentation supports.

The result: risk scores that accurately reflect patient acuity, stronger performance under value-based contracts, and reduced exposure in risk-adjustment audits.

01

Risk Adjustment Coding

Risk Adjustment Coding
CMS-HCCPayer modelsRADV

Risk adjustment models only work if the coding behind them is accurate and defensible. Our coders apply CMS-HCC and payer-specific risk adjustment methodologies consistently, so risk scores reflect the patients actually being treated - not just the diagnoses that were easiest to capture.

  • Coding aligned to CMS-HCC and payer-specific risk adjustment models
  • Consistent methodology across provider panels and networks
  • Audit-ready documentation trails for RADV and payer reviews
  • Improved accuracy in reimbursement tied to risk-adjusted contracts

The result: Risk-adjusted reimbursement that reflects true patient acuity, with coding that holds up under CMS-HCC and RADV review.

02

HCC Coding

HCC Coding
Chronic conditionsSpecificityPanel-wide capture

Chronic and complex conditions only count toward risk adjustment if they’re captured to the specificity the documentation supports. We identify every relevant HCC, code it accurately, and make sure nothing gets left behind.

  • Complete HCC capture across chronic and complex conditions
  • Coding to the highest specificity the documentation supports
  • Identification of missed or under-coded HCC opportunities
  • Consistent capture across large patient populations and panels

The result: HCC capture that reflects the true complexity of your patient population, and reimbursement that matches it.

Built for Providers and PAYERS.

For Providers

  • Stronger performance under value-based and risk-adjusted contracts
  • HCC capture that reflects true patient complexity
  • Audit-ready documentation across your panel

For PAYERS

  • Consistent risk adjustment coding validation across networks
  • RADV audit preparation
  • Reliable HCC capture across large member populations
Common Challenges

Common Challenges We Solve

If this sounds familiar, we should talk.

Chronic conditions under-documented or under-coded, morphing into severe revenue leakage and uncaptured patient acuity
HCC capture rates that don’t reflect true patient population complexity, leaving earned reimbursement on the table under value-based contracts
Risk-adjustment coding errors that create exposure under CMS-HCC and RADV audits, risking heavy clawbacks and financial penalties
Limited visibility into risk score accuracy across provider panels or networks, making it hard to identify coding gaps before audits occur
Inconsistent risk adjustment coding practices across a growing patient base, fragmenting data quality and inviting regulatory scrutiny
Difficulty preparing for RADV or payer-initiated audits, leading to operational disruption and administrative strain
The Impact

Understated risk scores, reimbursement that falls short of true patient acuity, and exposure under risk-adjustment audits.

Valerion Health exists to close these gaps - permanently.

FAQ

Risk Adjustment, Questions Answered

The right HCC coding and risk adjustment partner should support both providers and payers with accurate HCC capture, coding validation, and audit-ready documentation. Look for expertise in CMS-HCC and payer-specific models, along with a clear process for identifying missed HCC opportunities. Valerion Health provides risk adjustment coding support for provider panels and large payer networks, helping ensure risk scores accurately reflect patient population complexity.
Let's Talk About Your Risk Adjustment Strategy

Stop letting under-captured HCCs understate your risk scores.

Let's build a risk adjustment coding program that reflects the true complexity of your patient population - for providers and PAYERS alike.

Talk to a risk adjustment specialist

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