Healthcare organizations nationwide are struggling with HCC coding. It’s become a genuine mess.
Value-based care (VBC) promised salvation from fee-for-service models and the focus on quality instead of quantity. A great concept.
But the reality? Most providers are drowning in paperwork trying to capture those elusive Hierarchical Condition Categories.
McKinsey recently released some sobering news: While Medicare Advantage plans expect a 3.7% revenue bump in 2025, CMS is slashing payments by 2.45% through risk model revisions. Talk about giving with one hand and taking with the other.
That’s why Bulwark Healthcare’s RAQ+ platform deserves attention. The tool is genuinely changing how organizations handle HCC capture.
Let’s examine the problems it solves.
Major HCC Challenges Organizations Are Facing Daily
Anyone in healthcare knows the drill. One tiny coding error can torpedo reimbursements. Here’s what keeps administrators up at night:
1. Coding Complexity That Makes Heads Spin
The 2024 CMS-HCC update threw out over 2,000 ICD-10 codes. Just tossed them. Gone.
Meanwhile, coders juggle 70,000+ diagnosis codes in ICD-10-CM, and CMS just added 50 more procedure codes effective next April.
As many coding directors would attest, “Only a fraction of these codes map to HCCs, and missing even one means lost revenue.”
A study back in 2021 confirmed what industry insiders suspected—misclassifying chronic conditions tanks risk scores and cuts reimbursements. No surprises there.
2. Manual Processes That Belong in the 1990s
Organizations still doing manual chart reviews in 2025 are falling behind. The Office of Inspector General found nearly 8% of Medicare Advantage payments in 2017 were flat-out wrong.
Coders buried in paperwork can’t prevent money walking out the door. It’s an outdated approach that costs millions.
3. Compliance Risks That Could Sink Organizations
Last year, Medicare Part C had a 6.01% improper payment rate. That’s $16.6 billion down the drain.
Why? CMS reviews found documentation that was either—
- It was so illegible even doctors couldn’t read it (despite their notorious handwriting)
- Completely missing when auditors came checking
Compliance officers live in fear of penalties and legal actions. It’s like waiting for the other shoe to drop.
4. Provider Workflows That Drive Clinicians to Quit
Physicians didn’t spend years in medical school to become data entry clerks. Yet here we are.
Systems that don’t communicate force physicians to waste hours reconciling patient records. No wonder burnout rates are through the roof in healthcare.
5. Data Silos That Defy Logic
Having data is one thing. Using it effectively? That’s another challenge entirely.
A study in Angola found over half of hospital managers rarely use their Hospital Information Systems for decision-making because the systems are a fragmented mess.
The same problem plagues U.S. healthcare. Many health systems have mountains of data yet zero actionable insights.
HCC Capturing: RAQ+ Gets It Done
After countless failed “solutions,” Bulwark’s RAQ+ platform stands apart. It’s built for the real world of Medicare Advantage Organizations, ACOs, risk-bearing providers, and coding professionals seeking automated HCC capture and compliance.
Let’s go over its core features:
AI Does the Heavy Lifting
RAQ+ automates those mind-numbing workflows with remarkable precision. With the platform, you can:
- Detect inconsistencies across clinical documentation, minimizing RADV audit risks
- Identify miscoding by analyzing patient records, claims data, and EMR inputs
- Identify gaps and address them before submission with automated compliant queries
Realistic RAF Scoring
Medical groups implementing RAQ+ have boosted their RAF score recapture rates by 95%. As one CMO put it, “We’re finally getting paid for the care we’re actually providing.”
They’ve also cut clinician administrative workload by 80%. Doctors can focus on patients again instead of paperwork.
CMS Compliance Without the Headaches
Compliance officers at mid-sized ACOs have noted,
“RAQ+ keeps us aligned with CMS guidelines. We validate documents against claims and flag documentation gaps before they become audit findings.”
Organizations have reduced their medical loss ratios by 25%—a number that makes CFOs take notice.
Providers Who Can Practice Medicine Again
“We identify risk gaps in real-time now,” physician leaders report. “Our retrospective chart reviews are down 90%. We can actually practice medicine again.”
Why Forward-Thinking Organizations Are Adopting RAQ+
Hospitals embracing innovation are pulling ahead. The smart hospital market is projected to hit $148 billion by 2029 for good reason.
As a platform, RAQ+ does more than streamline risk adjustment. Here are the key benefits:
The ROI Is Substantial
Hospital systems implementing RAQ+ see an 11x return on investment. Revenue cycle directors report, “This technology pays for itself in months, not years.”
Financial Performance That Impresses Leadership
Traditional FFS-based risk adjustment is like trying to drive while only looking in the rearview mirror. RAQ+ uses EHR clinical data to get payment accuracy right the first time.
Finance teams are finding undocumented HCCs that previously slipped through the cracks, essentially reclaiming money they didn’t know they’d lost.
Audit-Proof Documentation
With denial rates hitting 11% of claims (up 8% from 2021), organizations need strong defense mechanisms.
RAQ+ automates pre-bill and post-bill Clinical Documentation Integrity (CDI) audits, minimizing denials and DRG downgrades. Its AI-powered anomaly detection ensures coding accuracy and compliance. No more worries about compliance.
Better Patient Outcomes (The Ultimate Goal)
Recently, Mount Sinai implemented autonomous medical coding for half their pathology cases.
Why?
Because accurate coding leads to better care coordination and ultimately, healthier patients. When documentation improves, care quality follows. It’s that simple.
Bottom Line
Organizations tired of leaving money on the table while watching staff drown in paperwork find RAQ+ delivers. Users report:
- 80% reduction in administrative busywork
- 95% boost in quality measure recapture
- Streamlined documentation that clinicians actually complete
Healthcare has seen plenty of “revolutionary” technology come and go. This solution stands out because it addresses real problems with practical results.
For healthcare leaders interested in seeing these results firsthand, requesting a demo of RAQ+ would be a logical next step. Coders, clinicians, and finance teams might just be grateful for the change.
Get a demo now!
