Prior to January 2000, CMS (Centers for Medicaid and Medicare Services), reimbursed health plans based solely on a members demographic information, (i.e. age, sex, location etc). In January of 2000, CMS began transitioning reimbursement to health plans according to a beneficiary’s health status. To accomplish this, CMS has implemented HCC, (Hierarchical Condition Category), a new risk adjustment program. HCC consists of 61 disease groupings based on inpatient and outpatient encounters. The HCC assigned to a disease is determined by the ICD-9-CM diagnosis codes that the Plan receives from the medical groups encounter data. Merlin Risk Adjustment assures that your Health Plan is receiving the appropriate reimbursement from CMS to pass onto the medical groups.

The merlin Risk Adjustment Software (MRA) supports medical record audits with secure movement of claims and encounter data for health plans and medical groups. MRA not only captures appropiate coding, but also provides notes regarding opportunities for coding improvement and summary reports for individual providers. Using a business rules engine, it is designed from the ground up to enhance productivity and bring unsurpassed levels of usability and sophistication to data coding projects. Distributed data coding teams can collaborate through a powerful Web-based environment to create, manage, validate and deploy data coding projects. Storan Technologies MRA's easy-to-use interface and rule-based functionality provides healthcare professionals with the tools to deploy and manage data recapture projects quickly and effectively. MRA has been used for medical record audits for over 750,000 medical records in multiple locations throughout the United states. A common use for MRA has been to support medical record audits for Medicare Advantage members in order to capture ICD-9 diagnoses that have been documented, but not correctly coded or submitted. Application of MRA software has consistenly provided clients with return on investment (ROI) of greater than 5:1.

The graph below shows the annual reimbursement of a 70 year old female.

Best Environment For Business Teams :   Simplicity   Control   Confidence   Ease of use   Scalability   Traceability and auditability - Work in your own familiar Web based environment, on your own time, separately but in sync with IT Assistance - Manage collaboration with role based permissions and rule metadata - Trace and audit coding patterns by coder, project, provider etc. - Get built-in assistance for ICD9 codes: templates, point-and-click editor, and error checking Simplicity - Work on shared projects without conflict or delay Predictability, measurability and consistency - Provides WEB based management reports for project history - Simplify complex coding projects through smart views, filters, and easy search and reporting - Create repeatable processes for project management and execution - See complete history of all chart reviews and corrections         - Roll back to previous configuration Testing and validation         - Verify coding validity with rule based engine and quality assurance process. Business simulation         - Predict impact of changes by testing against previous business conditions daily, weekly or monthly.