Case Study: Health plan’s Risk Adjustment Management Technology pilot results

Midwest health plan recovered over $5K per ACA member after a pilot of MedKoder’s Risk Adjustment Management Technology

Health plans and health systems are financially dependent upon the specific documentation of each individual patient’s diagnoses as classified within the highly specific CMS Hierarchical Condition Category (HCC) system and the management of those conditions. Failure to do so has both significant quality of care implications and financial consequences. To reduce risks, payers and providers either hire expert HCC auditors as an internal resource or look to outside vendors who are experts at executing risk adjustment and HCC auditing. For this million member Midwest health plan, an offshore review of their risk adjusted patient population prior to CMS submission did not result in reduced risks and there was a strong feeling that the premiums were not reflective of their members’ acuity levels. The Midwest health plan was impressed with MedKoder’s innovative technology solution to Risk Adjustment Management (RAM) that couples AI, Natural Language Processing (NLP), and industry leading talent. Thus, MedKoder was engaged to conduct a pilot with their RAM Technology to complete a secondary review on this health plan’s risk adjusted patient population and recovered over $5K per Affordable Care Act (ACA) member and $1,200 per Medicare Advantage (MA) member.

70% of the recovered opportunities were found after the secondary review:

Of the 205 ACA members reviewed, MedKoder’s RAM pilot recovered $1.1M. Additionally, MedKoder reviewed 152 MA members for this health plan and recovered over $182K, which recovered an average of $1,200 per MA patient, significantly higher than the usual average. The recovery amount for the ACA population is 5x’s the average found for the MA population. Once MedKoder received the data from the Midwest health plan, the VP of Risk Adjustment for this Midwest health plan received his findings in less than 2 weeks. He was impressed with how quickly implementation took and was astounded with the accuracy and results of his findings.

The results prove the necessity of secondary reviews and the significant quality and financial impact such this process can have on ACA and MA plans:

Although the future of the ACA is uncertain, CMS has continued to extend this coverage into 2018. Because of this, health plans should take advantage of the opportunity now to avoid revenue leakage, or owing funds to competitive payers. This study further clarifies offshore vendors lack in quality, efficiency, and reimbursement for the health plan.

As a service to all of its clients, MedKoder delivers the best ROI with over 20:1 return rate and results-driven risk adjustment solution to Medicare Advantage, ACA, and Medicaid plans of all types. A 98% accurate NLP with results which far surpass any other risk adjustment solution and implementation that removes the setbacks of health plan and hospital IT departments, MedKoder also provides value-added insight, quality, reliability, and financial peace of mind to ultimately provide health plans and health systems the funds they need to stay in business with value-based payment models and provide the best quality of care.

August 23, 2017

Click to learn more about MedKoder’s Risk Adjustment Management Technology.

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