Retrospective risk recapture powered by EXLCLARITY™


A small- to medium-sized health plan, based in southeast portion of the United States, with approximately 10,000 Medicare Advantage members, needed to better understand the CMS risk scores of the population and to identify any hierarchical condition categories (HCC) gaps where diagnosis may not have been captured accurately or applied accurately.

The client’s goal was to improve member outcomes, accurately capture all conditions and risks associated with the member, and improve CMS reimbursement.

The client needed to overcome a number of challenges:

  • Lack of clear line-of-sight into what was causing their risk scores to be lower than the previous year
  • Did not have analytics capabilities in house to pinpoint high-value members to target for medical record reviews
  • Required a platform or tool that would provide their operations teams with relevant information to supplement their medical record review process for retrospective risk recapture
  • Need to extract information in a customized layout to be further processed and submitted to CMS

Human ingenuity in action

To provide the needed visibility into risk scores and high-value members, EXL Health implemented and configured our proprietary platform EXLCLARITY™ based on the client’s needs and feedback, using advanced analytics to understand the population risk, locate gaps in documentation, and identify patients for outreach and visit scheduling to capture their risk score. The built-in chart review module was enabled to aid the client’s operations team identify risk adjustable diagnosis submitted on every claim, and also provided a method to make changes (add/delete/modify) to diagnosis codes based on findings from medical record reviews.

EXL Health also created a customized format in which to extract the data from the platform for further processing by the client.

The EXLCLARITY™ risk adjustment platform

EXL Health’s EXLCLARITY™ risk adjustment platform ingests a variety of data, including claims, labs, eligibility and CMS files to calculate risk scores at a member level. Risk scores are used by CMS in their calculations to determine payments to the health plan for the care of a member.

EXLCLARITY™ helps clients improve their risk scores in a variety of ways. The client used EXLCLARITY™ to generate targeted, actionable lists to help schedule member visits with the intent to provide care, recapture appropriate HCCs, initiate member outreach, and make critical information available at the point of care. This resulted in improvements to patient care and appropriate HCC reimbursement. The platform also delivers analytics and reporting to track the performance of specific programs that drive risk score improvement.

Chart review

EXLCLARITY™ was also used to identify members who may require additional retrospective risk adjustment reviews of medical records, leveraging the chart review functionality to review individual dates of service/encounters and to validate the accuracy of captured diagnoses. The client was able to view and modify diagnosis at a claim level, a system capability that ensures that all changes are tracked, audited, and then further processed for submissions to CMS. EXLCLARITY™ was also used to calculate the ROI of the program based on diagnosis codes submitted and any associated improvement in risk scores.

Business intelligence reports

EXL Health created comprehensive and interactive dashboards using Tableau to enable the client to view the data in a visual, easy to understand format. These actionable reports included custom filtering logic and provided drill-down capabilities to navigate information from summary levels down to an individual member level. The client also used EXLCLARITY™ for detailed reports and dashboards around risk adjustment factors (RAF), gaps, quality measures, financials, and performance scorecards.