The CareAlliance Model

Medicare Advantage

CareAlliance partners with practices to maximize Medicare Advantage outcomes through our proven model of:

Risk/Readiness Assessment
Payer Contract Negotiations
Technology Solutions
Best Practice Deployment & Ongoing Support

How partnering with CareAlliance boosts Medicare Advantage premiums

Typically, practices have focused solely on demographic data Adding claims data improves MA premiums Full HCC coding entails certified HCC coder review and yields significant results to premiums
76 years-old female .468 76 years-old female .468 76 years-old female .468
Medicaid Eligible .177 Medicaid Eligible .177 Medicaid Eligible .177
DM Not Coded DM (no manifestations) .118 DM with Vascular Manifestations .368
Vascular Disease not coded Vascular disease without complication .299 Vascular Disease with complication .41
CHF not coded CHF not coded CHF coded .368
No interaction No interaction +Disease Interaction bonus RAF (DM + CHF) .182
Patient Total RAF .645 Patient Total RAF 1.062 Patient Total RAF 1.973
PMPM Payment for Care $452 PMPM Payment for Care $743 PMPM Payment for Care $1,381
Yearly Reserve for Care $5,418 Yearly Reserve for Care $8,921 Yearly Reserve for Care $16,573

In Medicare Advantage models, the health plan is able to increase their payments from Medicare per patient by receiving improved:

  • HCC/RAF (Risk Adjustment Factor) Scores
  • HEDIS Star Ratings

As you can see above, the increase in the premium paid to the plan per member can be extraordinary if a practice is coding HCCs properly and improving HEDIS scores. This in turn leads to bonus payments and higher premiums to be paid from the plan to the provider.

Understanding HCC Coding

Each patient has a RAF score made of:

  • Baseline demographic elements (age/sex and dual eligibility status)
  • Incremental increases based on HCC diagnoses submitted on claims from face-to-face encounters with practitioners during the calendar year

HCC coding is prospective in nature

  • the work you do in this years sets the RAF and subsequent funding for next year

All models include chronic conditions that do not change from year to year

  • Diabetes, COPD, CHF, Atrial-Fib, MS, Parkinson’s, Chronic Hepatitis, etc.

By identifying missed HCC’s and properly coding them, this practice increased the premium their plan received by 134%, more than doubling the new payment made from the plan to the practice.

CareAlliance works alongside your existing team to improve HCC Coding through:


identify & Select HCC Codes - from providers, specialist, hospital discharge summaries, lab and diagnostic results

POC HCC Coding Guidance

Ensuring your team understand the significance of capturing at point-of-care.

Coding review

Between provider and coders, prior to claim creation.

Custom Extracts

From additional sources, based on your practice

HCC Code Suspecting

Overuse and drop-off alerts

Tracking Providers Utilization

Diagnoses by clinician and frequency to boost continuity

Post Visit Coder Training

Streamlining the process maximizing your coding and premiums

CareAlliance Partnership Model

While traditional consulting groups charge hourly with the annoyance of nickel and diming, CareAlliance enters into an Upside Partnership model with our clients. This completely aligns our interests with yours so that we are only compensated based off a percentage that we increase your collections.
Our Upside Partnerships are tailored individually for each client. Your specialties, geography, payer agreements, patient demographics, and existing workflows all play a vital role in developing a plan that is specific to your Medicare Advantage success.

Included in our Upside Partnerships is the security of knowing that CareAlliance’s ongoing support includes:

Regulatory Updates
EHR Customization
Practice/Provider Reporting
Workflow Enhancements
Coding Training