Challenge

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 HCC (Hierarchical Condition Categories) gaps where diagnosis may be not have been captured accurately or applied accurately. The goal was to improve member outcomes, accurately capture all disease risk associated with the member, and improve CMSreimbu rsement.

The client needed to overcome a number of challenges:

  • Lacked a clear line of sight to what was causing their risk scores to be lower than the previous year’s.
  • Did not have analytics capabilities in house to pinpoint high-value members to target for medical record reviews.
  • Required a platform/tool that would provide their Operations teams with relevant information to supplement their Medical record review process for Retrospective Risk recapture.
  • Needed to extract information in a customized layout to be further processed and submitted to CMS.

Human Ingenuity at Work

EXLClarityTM was setup and designed based on the client’s need and feedback to understand the risk score of the population and to identify any gaps in documentation, as well as identifying patients for outreach and scheduling visits 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 provide a method to make changes (add/delete/modify) 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.

EXLClarityTM was setup and designed based on the client’s need and feedback to understand the risk score ofthe population and to identify any gaps in documentation, as well as identifying patients for outreach and scheduling visits to capture theirrisk score.

RISK ADJUSTMENT

The EXLClarityTM risk adjustment platform ingests a variety of data like claims, 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. EXLClarityTM helps clients improve their risk scores in a variety of ways, including:

EXLClarityTM can generate targeted/actionable lists to help with scheduling member visits with the intent to provide care, recapture appropriate HCCs, initiate Member outreach, or make critical information available at the point of care. This helps our clients in improving patient care, as well as getting appropriate HCC reimbursement. EXLClarityTM has the analytics and reporting that enables our clients to track the performance of specific programs that are instituted at improving their risk scores.

CHART REVIEW

The client uses the EXLClarityTM platform to identify members who may require additional retrospective risk adjustment reviews of medical records. They then leverage the chart review functionality within EXLClarityTM to review individual dates of service/encounters and validate if all diagnosis was accurately captured. The users have the ability to view and modify diagnosis at a claim level. These changes are tracked, audited and then further processed for submissions to CMS. EXLClarityTM enables clients to calculate the ROI of their program based on diagnosis codes submitted and any associated improvement in risk scores.

BUSINESS INTELLIGENCE REPORTS

Comprehensive and interactive dashboards have been created using Tableau to enable the client to view the data in a visual, easyto-understand format. These actionable reports have drill-down capabilities to navigate information from summary levels down to an individual member level. Clients have a variety of reports and dashboards for that they can setup custom filtering logic to identify their target set of members for outreach or chart reviews. EXLClarityTM provides detailed reports and dashboards around RAF, Gaps, Quality measures, Financials, performance scorecards, etc.

Outcomes

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