Canada
Puerto Rico
USA
Belgium
France
UK
India
Client Background
The client is a non-profit, mission-driven health plan that offers quality, affordable coverage in retail, Medicaid and Medicare lines
Client Need
System to process encounters in CMS-RAPS and EPDS (post adjudicated claims 8371/P and DME – Durable Medical Equipment), this includes editing and processing of supplemental data
Analyze star rating measures, improve care management and create interventions for high-risk patients
Create a better risk adjustment system that can handle the supplemental data collected through the chart review process
Consulting for a value-based payments healthcare initiative
Reduce time taken to review patient medical charts and improve review accuracy
Solution
Built a system to send all variations of encounters including standard, void and adjusted encounters from payer system to CMS
Utilized the Model Output Reports (MOR) to identify Hierarchical Condition Categories (HCC) gaps in care management and created interface to carry out interventions for suspected patients
Built a system than can carry out retrospective analysis using the suspect member details for chart review and performed linked, un-linked claims submission to CMS
Analyzed the current process of provider reimbursement and detailed out the implementation strategy for episode of care to treat Asthma, COPD, Heart Failure, Upper Respiratory Infection
Implemented OCR to process the scanned medical charts and pull out relevant medical information (rule-based) to pass through NLP engine
Realized Benefits
Increased CMS EDPS acceptance rate by 5% and accurately reconciled RAPS and EDPS responses.
The client is now able to prospectively target high-risk populations, manage care 50% more effectively and is seeing improved ratings for their plans.
Over 5% improvement in the year-on-year average risk adjustment capitation rate.
Enhanced quality of treatment for patients and saved over $1.6 million in payments to provider groups in the year of the implementation.
Reduced manual efforts by 20% and dramatically improved reporting accuracy.
Tools & Technologies
HYE
Microsoft SQL Server
Information Builders WebFOCUS
Greenplum Database
Microsoft .NET Framework
IBM Infosphere DataStage
Mongo DB
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