Medicare Advantage & Medicaid Risk Score & Revenue Management
Health Care Analytics can help your organization design and implement strategies & tactics to manage risk adjusted premium revenue through a multi-pronged approach including appropriate coding, application of provider & health plan decision support tools such as patient coding profiles, expert data analysis, risk score & premium computation for forecasting & predicting risk scores to measure ROI as well as financial impact analysis of intervention & programs
- Strategies for accurate ICD9 coding and encounter data submission
- Report & tool development for comprehensive & appropriate coding
- Data analysis to identify encounter data gaps, code leakage and over-coding impacting revenue
- Encounter data auditing & analysis using RAPS return data
- Comparison of risk scores & premium revenue, CMS vs. health plan data
- HCC analysis, risk score & premium revenue calculation using CMS SAS program
- Revenue / medical cost margin (MLR) analysis
- Risk Adjustment Analysis
- Provider Profiling & Performance Measurement
- Premium Revenue Forecasting & Reconciliation
- Financial Impact Analysis
- Strategic Marketing Analysis
Case Study: Large California IPA & Medicare Advantage MCO
Optimize premium revenue by implementing a comprehensive risk score management program
Services provided included chart audits and provider education to optimize coding, provider & health plan decision support tools such as patient coding profiles, systems and workflow audit and analysis to identify and correct systematic loss of encounter and ICD9 data, data analysis, risk score & premium computation for forecasting & predicting risk scores to estimate future revenue booking, measuring ROI and financial impact of intervention & programs and re-engineered processes, and analysis for premium reconciliation. The project lasted 2 years and most of the initiatives implemented are still in place.
»6-10% total revenue increases for Medicare books of business, ROIs ranged from 3:1 to 5:1
Case Study: 5 Large at Risk Physician Groups & Medicare Advantage MCO
Chart audit, coding optimization & physician education program
Services provided included chart audits and provider education to optimize coding, provider & health plan decision support tools such as patient coding profiles, data analysis, risk score & premium computation for forecasting & predicting risk scores to measure ROI and financial impact of intervention & programs.
»10% total revenue increases for their Medicare books of business and realized an ROI of between 4:1 and 8:1
Case Study: Small Medicare Advantage SNP
Retrospective chart audit project aimed at recovering missed diagnoses codes
Data analysis, risk score & premium computation for measuring ROI and financial impact of intervention, RAPS data submission to CMS, inventory and analysis of RAPS return error data, and specialized decision support analysis for identifying and prioritizing auditing activities.
»Estimated revenue gain is 6% with an ROI of 5:1
between 4:1 and 8:1