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Risk Adjustment – Second Level Review: 20% more risk factors added across 1M+ Medicare Advantage members

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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

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