Our Stories

Our Stories

Risk Adjustment, Data Validation, and Medical Record Review Expertise

RELI performs validation reviews as the RADV contractor for both the CMS Center for Program Integrity (CPI) MRRC A contract and as the Medicare Part C Improper Payment Measure (IPM) National RADV contractor. RELI performs claim reviews as the Medical Review Accuracy Contractor (MRAC) for CPI and performs medical case review and coding and document management for the Consumer Product Safety Commission (CPSC). RELI supplies teams of coders, abstractors, nurses, physicians, and program managers to review, document, and analyze CMS and CPSC data. RELI has established accuracy and quality processes resulting on average in 98% or better accuracy. RELI has processed more than 150,000 RADV medical records through various processes such as submission, intake, and abstraction. We have processed over 11,000 accuracy reviews including disagreement notifications and rebuttals. RELI has abstracted and coded over 850,000 injury data cases and processed over 90,000 documents for CPSC. With subject matter experts in RADV, Medicare Policy and Nurse Reviews, and NEISS coding, RELI retains an unparalleled knowledge of the total risk-adjustment data-validation process, Medicare Part A, B, and C policies, and CPSC NEISS guidelines.

Research Required by Congress

With a team of doctoral-level research SMEs, RELI helped strengthen the US Government’s ability to provide better healthcare for populations and better care for individuals, all while reducing cost. We provided the data validation, sampling, and analysis required to fulfill Congress’ mandate to examine fraud, waste, and abuse in the Medicare program under Medicare Access and CHIP Reauthorization Act (MACRA) Alternative Payment Model (APM). RELI’s recommendations are instrumental in providing CMS with the means to identify policy solutions to reduce, fraud, waste, and abuse. Furthermore, RELI has provided CMS with a deeper analysis of patient selection behaviors among Accountable Care Organizations (ACOs) that prevents fraud, waste, and abuse in the Medicare Program. In addition, our findings within the Medicare Shared Savings Program (MSSP) was of great value to the US Government as it informed the development of all future Medicare APMs. According to CMS, the MSSP is the largest shared savings program in the Medicare Program, supporting 11.2 million beneficiaries (CMS 2020). RELI uncovered a potentially major data vulnerability within the MMSP program, which directly benefited the US Government and future APMs. RELI also presented CMS with better visibility for resource allocation. As our analysis on risk score trends for Comprehensive Primary Care Plus showed that there was no evidence of upcoding occurring within the model, CMS was able to redirect its limited financial and staff resources to prevent other APM vulnerabilities.

A PMO that Embodies RELI’s Success Across Government and Commercial Entities

Our PMO is agile, consisting of highly qualified Certified Scrum Masters (CSMs) and SAFe certified Agilists (SAFe® 4.0), to support programs in management, contract administration, quality assurance, risk, and transition management. RELI’s PMO manages project teams using various software methodologies (e.g., Waterfall, Agile). We use these methodologies to execute the work, mitigate risks, resolve issues, and measure the performance of project-related work. Our Portfolio Management, Program Management, and Project Management (PM3) subcontract demonstrates RELI’s ability to provide highly complex PMO services. These skilled services supported the development of plans and procedures, program coordination and service delivery integration, quality assurance surveillance, performance and service level monitoring, compliance audits, and reporting. RELI’s PMO practice ensures our customers benefit from mature portfolio, program, and project management practices that support the highest quality deliverables, which are on-time and within budget. Our PMO is supported by a toolkit of procedures, processes and tools that are CMMI Dev Level 3 and Project Management Body of Knowledge (PMBOK) aligned. RELI has demonstrated experience anticipating needs in fluid environments, working to ensure that roadblocks are identified and addressed before they impact schedules. Using SAFe/Agile principles, RELI successfully optimized work flow to produce high quality solutions, while saving time and reducing costs.