Client Background and Context
National Health Plan with 3.5M+ members. The Fortune 500 client found gaps in their coding & claims data collection/submission process for a subset of their ACA population. The client wanted to ensure accurate & complete code capture with compliance and quality.
Solution
- 2nd level review through NLP and certified coders on charts previously reviewed by another vendor
- Leveraged flexible solutions for chart review in entirety to validate conditions, find deletions & identify missed conditions
- Accurate HHS-HCC risk scores for appropriate reimbursement
Impact delivered
- 13% higher risk factors conditions identified (HHS-HCC risk score increased from 3.89 to 4.4) from Level 1 to Level 2
- 12% increase in conditions from first level review of reviewed member population
