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Martlet AI Blogs
New product features, the latest in technology, solutions and updates
RxHCC Risk Adjustment Model in Medicare Part D
RxHCC stands for Prescription Drug Hierarchical Condition Categories. It is the risk adjustment model CMS uses specifically for Medicare Part D — th...
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What Are HCC Coding Gaps
HCC coding gaps occur when a patient's chronic conditions are present in their clinical history but do not make it into the risk adjustment data sub...
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Medicare Advantage Rates
Every private insurer running a Medicare Advantage plan gets paid by the federal government to do it. Those payments — monthly, per member, calibrat...
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HCC Risk Adjustment Coding
Billing in Medicare Advantage does not work the way it does in fee-for-service. Providers do not get paid per procedure. Health plans receive a mont...
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HCC v28
CMS does not update its Medicare Advantage risk adjustment model often. When it does, the changes ripple through every health plan's finances, codin...
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Prospective vs Retrospective Risk Adjustment
Health plans and provider organizations do not have a single moment to get risk adjustment right. Patient conditions need to be documented, coded, a...
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Risk Adjustment Factor
The Risk Adjustment Factor (RAF) is a numeric score that healthcare payment systems use to estimate how much a given patient is likely to cost relat...
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AI Risk Adjustment
Risk adjustment has always been a data problem. The model is only as accurate as the diagnoses feeding into it, and diagnoses are only as complete a...
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AI in Medical Coding and Billing
Revenue cycle teams did not start using AI because it sounded innovative. They started using it because the volume of routine encounters outgrew wha...
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Risk Adjustment Coding
Healthcare has never paid everyone the same rate. A patient managing diabetes, heart failure, and chronic kidney disease costs far more to cover tha...
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Hierarchical Condition Category (HCC) Coding
HCC coding is the risk adjustment methodology CMS uses to estimate patient disease burden and calibrate reimbursement in Medicare Advantage and othe...
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70% of AI-Generated HCC Suspects Were Rejected. Here's Why That Happens
Hierarchical Condition Category (HCC) coding is one of the areas in healthcare where AI is the obvious solution. On paper, it makes perfect sense. Use...
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How Healthcare-Specific Language Models Are Transforming HEDIS and Stars Performance
Healthcare-Specific Language Models — AI models trained exclusively on clinical and biomedical data that accurately understand medical terminology, cl...
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RADV Audit Readiness for Health Plans: Reducing Clawback Risk and Strengthening Compliance with AI-Driven Workflows
Clawback Risk — the financial exposure a health plan faces when unsupported diagnoses identified in a RADV audit sample are extrapolated across the fu...
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RADV Audit Readiness: What Compliance Teams Should Ask Their Vendors
Audit-Ready HCC Coding Platform — a compliance-focused system that applies current CMS payment-year rules to risk-adjusted diagnoses, links each HCC t...
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