Foundational risk adjustment transformation drives significant improvement in value-based programs

NEMG Partners with EXL Health, leveraging embedded data & analytics in its operations, to achieve sustained value-based care performance results for risk-bearing Medicare population


  • NEMG started with a risk adjustment proof of concept, with the goal to determine outstanding risk for recapture. After launching the program, the client achieved significant success, and expanded their partnership with EXL Health.
  • Since 2018, NEMG has been able to accurately report the risk of their Medicare Advantage population, allowing them to negotiate more effectively with Medicare Advantage Plans and achieve better reimbursement rates.
  • NEMG has succeeded in enhancing quality of care, improving coordinated care and delivering a superior patient experience, which in turn has led to significant shared savings from the CMS in one year.
  • Of the 18 ACOs in their region, NEMG attained the highest total savings for CMS in 2020.
  • EXL Health and NEMG worked in partnership, with EXL Health serving as an extension of NEMG’s risk adjustment and value-based care team. EXL Health proactively reviewed and provided analysis and offered recommendations for NEMG to implement to affect change.
  • EXL Health is now expanding its risk adjustment and quality management services to other patient communities within NEMG to help them further improve patient care while lowering costs and improving risk adjustment outcomes.

The challenge

Northeast Medical Group (NEMG), a not-for-profit multispecialty medical foundation, is part of Yale New Haven Health, Connecticut’s leading healthcare system. Established in 2010, NEMG has more than 130 community practices in Connecticut, Rhode Island and New York. NEMG doctors include specialties such as pediatrics, cardiology, gastroenterology and podiatry. NEMG patients have access to five affiliated hospitals: Yale New Haven, Bridgeport, Greenwich, Lawrence + Memorial, and Westerly.

NEMG is an accountable care organization (ACO) which requires physicians and other healthcare practitioners to provide coordinated care to improve patient outcomes and reduce overall costs. An ACO is part of a shared savings program specific to the Center for Medicare and Medicaid Services (CMS). A key component of this program is that an ACO receives a portion of any savings that result from reducing costs while meeting quality requirements.

NEMG has 835 physicians and medical professionals and serves approximately 200,000 patients annually, including a significant Medicare population. The healthcare system did not have accurate reading of their risk score represented in this patient population. This prevented them from being able to estimate the level of risk they could take on for both their Medicare Advantage and ACO populations. An ACO’s risk score is directly related to reimbursement rates from CMS.

NEMG needed to determine a realistic projection of the clinical and financial risk carried by their Medicare patients, which ultimately would allow them to better provide high-value, patient-centered care. NEMG turned to EXL Health not only for its technology solutions, but to work as a partner providing operational support, analytics, and real-world recommendations for NEMG to implement to improve their patient and business outcomes.

Human ingenuity

EXL Health and NEMG began working together to address one pressing issue—how to accurately represent risk. This partnership began with an initial project where EXL Health conducted a medical records review to determine an accurate risk score for NEMG. The EXL Health team collected data from a small sample of Medicare Advantage patients and used advanced analytics techniques to identify gaps and opportunities for risk recapture. The findings allowed NEMG to ensure appropriate risk scores that may have not been accurately represented due to gaps in documentation or coding inaccuracies.

Following this initial success, EXL Health then analyzed a larger group of medical records, examining 1,000 charts during a six-month period, and then 5,000 charts, and then the entire Medicare population. In parallel, EXL worked with NEMG to setup a prospective & concurrent medical record review process to ensure a patient’s risk was being accurately documented during the annual wellness visit or scheduled encounter with a primary care physician.

To do this work, the EXL utilized the EXLCLARITY™ risk adjustment and quality platform. This technology solution brings together data from disparate sources to create a 360-degree view of a population’s risk. The system has a robust data management process that provides verifiable results about current performance. It also included a suite of business intelligence reports and performance tracking capabilities.

As the EXL Health team expanded their records review work, they had a clearer picture of current performance specific to medical coding and risk adjustment. Rather than provide a series of reports, the team proactively sent specific information to the NEMG team that they could act upon and real-world strategies they could implement.

An active and collaborative partner, NEMG was receptive to implementing best practices and tailored solutions, managing the programs with keen dedication and awareness to best serve their patients and providers. Together, the NEMG and EXL Health teams evolved four broad strategies to improve risk adjustment performance:

Chart reviews. The EXL team defined a prioritization algorithm based on a variety of factors like estimated gaps in coding, a provider’s coding efficiency, severity of suspected conditions, last patient encounter etc. This along with bi-directional risk adjustment coding enabled EXL to deliver improved documentation accuracy and highest value to NEMG.

Provider education. Based on the findings from the chart reviews and the analytics platform, EXL Health merged this data to develop a shortlist of healthcare providers who needed additional training about what coding practices should be followed so they are accurately representing risk.

Additionally, the EXL Health team curated content for the NEMG team to use during these provider education sessions to make these meetings as personalized and targeted as possible, and revised the target list for education every year based on performance. NEMG actively participated in this strategy, providing provider-centric feedback for EXL Health to incorporate and continuously improve the approach. The personalization increased the effectiveness and engagement, as providers were shown only content and education tailored to their needs and interests.

Patient outreach. The EXL Health team realized not enough patients were coming into the office for their annual wellness exams, which is the one visit per year where a physician can gather the most information about their patients. EXL recommended to NEMG that they conduct an outreach campaign to promote these visits. The team also provided a prioritized list of patients for NEMG to contact based on those who were deemed the highest risk for poor health outcomes.

NEMG worked with their provider offices to schedule appointments and coordinate care. The efforts were successful, as 80% all patients were seen in 2020, at the height of the COVID-19 pandemic.

Continuous feedback. Once the NEMG team started implementing these recommendations, the EXL Health team provided ongoing feedback, letting them know what was working based on the data they could see within the EXLCLARITY™ platform. This information was continually updated and outcomes changed based on information coming into the system. This feedback gave the NEMG team confidence in the system and visibility into the entire process.

The NEMG team implemented these recommendations with significant results. They conducted nearly 100 in-person meetings with physicians and other medical professionals and delivered medical coding education specific to the needs of each provider.

“NEMG had a problem they were looking to solve. We viewed our relationship with NEMG with the goal of helping them achieving success. That changed our entire mindset in how we worked with them. We started using our own data to see what more could be done towards their goal. This led us to develop and share operational recommendations they could implement—minor changes to daily activities that ended up driving real change,” said Varun Pandarathil, senior assistant vice president, Risk Adjustment Analytics, EXL Health.

The outcome

Both EXL Health and NEMG view their ongoing partnership as hugely productive for all stakeholders, especially the patients and practitioners of NEMG. In October 2021, NEMG officially announced their successful work to enhance quality of care, better coordinate care and deliver superior patient experience. NEMG also has continually improved quality scores for patient care, year over year, achieving a score of 98.44 out of 100 in 2020, despite the COVID-19 pandemic. Also during 2020, ambulatory patient experience scores were sustained above the 90th percentile nationally or in the top 10 percent in the country.

Beyond improved patient care and cost savings, EXL Health continues to provide three key benefits to NEMG: working in collaboration, a view for long-term success, and a best-in-class technology platform.

Collaboration. EXL Health continues to work with NEMG taking a consultative, collaborative approach to understand their pain points and challenges and help them define operational strategies. The EXL Health team continually returns to the data, asking the right questions to develop analytics, and then translating that into business insights that can be implemented in real-life environments. EXL Health remains as an extension of the NEMG core team, providing operational support to achieve their goals in patient and business outcomes.

Long-term view. Based on this collaborative effort, EXL Health is looking at a long-term picture regarding the patient, business and operational goals of NEMG. The team is developing a roadmap with clear steps to move NEMG forward to deploy advanced operational strategies. For example, EXL Health would like to utilize more technology rather than manual processes for some their data collection and analysis. The EXL Health team also proposes to expand their records review work to include all of NEMG’s patient population. Additionally, physician education could be extended to specialists and other medical professionals.

Technology solution. All of the insights and recommendations that have resulted in real-world recommendations for NEMG operations are based in part on the EXLCLARITY™ platform. This best-in-class technology offering has and continues to be used by different personas within NEMG, such as medical coders, analysts and business managers. While the NEMG team has complete visibility into the platform, the EXL Health team will continue to operationalize data and provide recommendations to make impactful change.