Insurance payer's RAF score improved from 1.5 to 2.1, which helped them improve their financial performance by 40%

The client:

The client is a plan covering a diverse Medicare Advantage population with close to 6000 members.

Challenges faced:

• RAF Score <2.1 for the last two years
• Potential leakage of Dx Codes required for risk adjustment Submissions.
• Incomplete and inaccurate documentation of member diagnoses.
• Lack of tools and technology to identify RAF gaps and prioritize interventions.

Plutus Health plan:

Plutus Health's experts recognized that the client needed an advanced analytics solution. We offered our expertise in healthcare analytics, technology, and risk adjustment methodologies to address the challenges faced by the payer.

Issues detected:‍

• Lack of expertise and resources in accurate HCC coding.
• Missed capture of chronic conditions
• Limited visibility into coding processes and opportunities for improvement.
• Communication gaps between care providers and the insurance payer.
• Unable to retrieve medical codes.

Plutus Health solution:

• Conducted a thorough chart review of the client and identified potential gaps in HCC coding.
• Certified HCC coders abstracted all HCC conditions from the medical records as per MEAT or TAMPER records.
• CRC-certified coders appropriately identified and captured the Dx Codes.
• Precisely added chronic condition codes.
• Performed regular coding audits to identify discrepancies and provide coding staff feedback.
• Abstracted medical records for all HCC conditions and assigned appropriate ICD-10-CM codes.
• Conducted educational programs to train coding staff on best practices, coding guidelines, and accurate RAF documentation.
• Accurately used cutting-edge technology to extract all HCC conditions from medical records to increase accuracy and reliability.

Results:

• The client saw a significant improvement of 40% in RAF scores.
• Appropriately captured missed chronic condition codes.
• The client's risk adjustment solutions got >98% acceptance.
• There was a more precise reflection of the population's risk profile, leading to higher reimbursements.
• The client's financial performance improved by 40%.
• There were improved documentation practices, accurate capture of member diagnoses, and a better understanding of the importance of RAF coding.
• The automation and advanced analytics capabilities captured 50% more missed code opportunities, ensured compliance with coding guidelines, and improved overall coding efficiency by 90%.

Achievements:

• The client's RAF score improved from 1.5 to 2.1.
• The client successfully addressed RAF gaps and significantly improved their RAF scores by 40%.
• The client saved 60% of its cost on each medical chart review.
• The client had a better alignment of reimbursement with the true risk profile of the member population.