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Medicare Advantage organizations juggle three critical revenue streams: risk adjustment accuracy, quality performance scores, and clean encounter submissions.
Most struggle with fragmented systems that don't talk to each other, leading to missed revenue, compliance risks, and operational inefficiency.
We've built our platform from the ground up to address these interconnected challenges. By unifying risk, quality, and encounter management, we help you capture every dollar you've earned while reducing administrative burden.
Our modular approach means you can start where you need help most—whether that's improving HCC capture rates, closing Star rating quality gaps, or cleaning up encounter rejections—then expand as you grow.
While others piece together point solutions, we've built the only unified platform that connects risk adjustment, HEDIS quality measures, and CMS encounter submissions. One platform. Complete visibility. Proven results.
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Take a look at Confianza's products
It is challenging for every health plan to perform Encounter Data Processing reconciliations, or to prioritize encounter correction efforts using risk scores. Our experience dealing with the complexities of this process drove us to create simplified, highly optimized product suite to cater these needs. Medicare advantage health plans can now drill down to the details, forecast results and reallocate resources and much more at the click of a button. Confianza's solution will help the risk manager to identify and prioritize encounters by risk, reconcile discrepancies and positively impact revenue.
Import any file format and map and transform data into 5010 X12 837.Perform HIPAA and CMS specific edits.Manage and quickly interpret CMS error reports.Create 837 from corrected EDPS data for re-submission to CMS.
Create RAPS file from 837 files submitted in EDPS. Web enabled manual entry of RAPS data Ability to validate and edit RAPS data to minimize errors defined by CMS as avoidable rejects Identify and remove duplicate RAPS cluster from RAPS submission files Ability to delete CMS accepted cluster online.
Dahs boards to represent file processing status and schedule live. Dash boards to represent File status. Dashboards to represent encounter rejections by category. Provision to create custom reports. Customizable APIs to extract data.
Automatically classify CMS rejections by type (Provider, Diagnosis, Procedure etc...). Rank and prioritize error correction activities by risk score Manage and quickly interpret CMS error reports Define and reconcile discrepancy gaps between EDPS and RAPS Define and reconcile discrepancy gaps between MAO-002 and MAO-004 Tracking of source files and reconciliation with CMS responses and reports. Tracking of diagnosis back to source files and reconcile with CMS responses and reports.
The Medicare Advantage plans relies on CMS risk adjustment to maintain predictable and actuarially sound payments from CMS, to provide better care for its enrollees. Keeping patients healthy and out of the hospital is the main goal for every health plan. Confianza offers a stable risk adjustment system, essential to ensure sustainability in benefits provided to enrollees and to the continued innovation in the delivery of high quality, coordinated, and affordable care to Medicare Advantage enrollees.
Identify various gaps such as Retrospective, Perspective and Predictive gaps that can help providers to better manage member’s health.
Accuracy in identifying revenue leakages by projecting opportunities on medical records that were left out either because of internal audits or through CMS rejections.
Assists MAPD plans in identifying members with chronic conditions that do not take drugs, which will help health plans to reduce ER visits.
System has the capability to scan through plan's EMR data and identify possibility level of having a combination of diagnosis codes. Ability to correct claims or create CR’s for a missing diagnosis code from an existing medical record. Provides analytical data for providers to understand and better manage member’s health, based on the past diagnosis. Projects risk score and revenues on an ongoing basis as CMS accepts claims that are risk eligible. Accuracy in projecting MLR that will assist health plans in making decisions to bid for a particular county or region
Quash the complexity of member HCC risk and premium capture with our easy-to-use analytics suite. Identify HCC opportunities in plan population using our advanced algorithms. The Confianza predictive solution can provide pinpoint accuracy for predicting premiums receivable from CMS. Use out products to create chart reviews in EDPS/RAPS, store member level HCC date and accomplish more.
Quickly identify opportunities for RAF improvement within plan population with a clean, simple, robust interface.
Calculate RAF score, based on EDPS & RAPS submission data.
RAF Dash board to display current and projected RAF score of plan population.
RAF break down for EDPS & RAPS. Store and report on member HCC history. Provide member level RAF score and HCC details. Drill into each member to get detailed information, including demographics, providers, encounters, RAF details, HCCs captured. Provide user interface to create linked as well as unlinked chart reviews for missing diagnosis in EDPS.
Automatically identifies which members qualify for each CMS Star measure—using age, enrollment, diagnosis, procedures, labs, and pharmacy criteria.
Runs the latest CMS specifications across 90+ measures to compute numerators/denominators and per-measure, per-domain Star scores at contract, provider, and member levels. .
No guesswork. See structured, traceable evidence for every compliant or non-compliant case—dates, codes, clinical notes, and references (ICD-10, CPT, LOINC, NDC, SNOMED).
Flag non-compliant members, quantify Star impact, and surface root causes—missing screenings, overdue labs, adherence issues, or documentation gaps—with clear next-best actions.
Ingests claims, lab, and pharmacy feeds (plus EHR/clinical data when available), normalizes to measure logic, and plugs into existing workflows via secure APIs.
Enterprise security end-to-end. Our AI chart-review partner validates hybrid measures from uploaded records and highlights exactly where evidence appears in the chart for fast auditor confirmation.
One of the major challenges in managing Medicare Advantage plans is receiving accurate premium payments from the Centers for Medicare and Medicaid (CMS). Inaccuracies with member eligibility information and disease status markers mean health plans are missing millions in premium.
Confianza’s MSP experts can help you restore the premiums you deserve by proactively managing disease statuses and optimizing Medicare advantage revenue. We ease the administrative burden of finding errors and making corrections and ultimately restoring millions of additional premium dollars for your plan.
Our analytics tool helps to quickly and accurately identify records that indicate primacy discrepancies that may negatively impact your premiums.
Create ECRS transactions to correct invalid records for premium.
We validate and Store critical MSP information at a member level.
Automatically importing members with information relating to their secondary payers, which simplifies the identification of reimbursement opportunities from secondary payers and mitigate potential revenue shortfalls.
Automation that reduces health plans’ manual labor and operational costs.
Automation that ensures proper primary or secondary payment and recovery of overpayments
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