Client Background and Context
- National Health Plan with 6M+ members of which 1M+ MA. The client found gaps in their coding & claims data collection/submission process. The client wanted to:
- Overcome issues in collecting the correct data and documentation
- Fix the incomplete HCC risk score
- Ensure correct addition/deletion data is sent to CMS
- Mitigate exposure if selected for an RADV audit
Solution
- 2nd level review on a subset of MA members (~0.5M charts) which validated 92% of existing condition codes
- Leveraged coding talent to review charts in their entirety to find deletions & identify missed conditions
- Accurate HCC risk scores for appropriate reimbursement & mitigation of RADV audit exposure
Impact Delivered
- 20% higher risk factors identified (HCC score increased from 3.75 to 4.5) leading to increased reimbursement
- 10% increase in conditions from first level review of reviewed member population
