our-stories

Our Stories

Risk Adjustment, Data Validation, and Medical Record Review Expertise

To support CMS in their health-related mission, RELI has supplied teams of coders, physician reviewers, and program managers to ensure the evaluation and analysis of medical data are documented and reviewed. RELI has demonstrated an inter-rater reliability (IRR) of 97.2% on the 2015 National RADV sample for validation review and a coder agreement of 96.2% on the 2013 Contract-level sample. This work has been a major benefit to CMS, as our average Coder agreement rate was higher than the industry standard of 95%. RELI has processed more than 55,000 medical records through various processes such as submission, intake, and abstraction; and we have the capability to process more than 6,000 medical records per month. We have further demonstrated our expertise by performing over 46,000 submission review quality checks and over 38,000 medical record intake and validity checks. Additionally, RELI has completed more than 45,000 medical record coding reviews. Our team of coders has been performing CMS risk adjustment data validation for more than 4 years, providing RELI with an unparalleled knowledge of the total risk-adjustment data-validation policies, processes, and tools. RELI has achieved an Excellent/very good CPARS rating as the Risk Adjustment Data Validation (RADV) Medical Record Review Contractor (MRRC).

Essential Research Required by Congress

With a team of doctoral-level research SMEs, RELI has helped strengthen the US Government’s ability to provide better healthcare for populations and better care for individuals, all while reducing cost. To accomplish this, we have 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 produces recommendations that are instrumental in providing CMS with the options it requires 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. The MSSP is the largest shared savings program in the Medicare Program, supporting 7.2 million beneficiaries and expending more than $60 Billion in Medicare funds annually. RELI uncovered a potentially major data vulnerability within the MMSP program as well, which also 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 CPC+ showed that there was no actual evidence of upcoding occurring within the model, CMS was able to redirect its limited financial and staff resources to preventing other APM vulnerabilities.

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

Vice President, Ms. Tish Mossman leads our PMO, leveraging over 25 years of experience delivering large complex programs and establishing PMOs for both commercial and government entities. Our PMO is agile, consisting of highly-qualitied, Certified Scrum Masters (CSMs) and SAFe certified Agilists (SAFe® 4.0) to support programs in areas of management, contract administration, quality assurance, risk, and transition management. RELI’s PMO has managed project teams using various software methodologies (i.e., Waterfall, Agile) depending on the project need. These methodologies were used along with processes and procedures 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 is optimized to ensure our customers benefit from mature portfolio, program and project management practices that support the delivery of initiatives on-time, within budget, and with the highest quality. Our PMO is supported by a toolkit of procedures, processes and tools that are CMMI L3 Dev and 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, saving time and reducing cost.