New Predictive HCC Risk Adjustment Solution Helps HMO Increase Revenue Capture by 2.5 Million in First 6 Months

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VitreosHealth offers first-of-a-kind free population assessment to identify untapped undercoding opportunities

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The integrated workflows with embedded analytics helped increase our productivity by 25% and reduced our undercoding by 15%. - Carey Ketelsen, GlobalHealth's Executive Director

VitreosHealth Predictive HCC Risk Adjustment solution leverages advanced data analytics to accurately understand each Medicare Advantage member’s risk, identify any gaps-in-coding, as well as gaps-in-care to ensure proper reimbursement for a given population. This new solution helps transform the HCC Risk Adjustment process from a typical fragmented process to a technology-enabled process utilizing advanced predictive analytics.

HCC Risk adjustment is one of the top untapped opportunities for an HMO or Provider group taking on risk with Medicare, Medicaid, or dual-eligible contracts. Accurate HCC coding information helps create a more complete picture of the complexity of a patient population and improve premium revenue capture while maintaining compliance

VitreosHealth’s Predictive HCC Risk Adjustment solution identifies patients with undercoding opportunities by leveraging:

  • Adaptive, learning Extract-Transfer-Load (ETL) process to scout EMR, claims, billing, pharmacy, lab results, ADT, Mental Health, HRA files to create a 360-degree longitudinal view of the member record
  • Disease specific predictive modeling platform to capture any emerging complications with chronic disease progression
  • Multi-dimensional OLAP model to propagate chronic condition diagnosis from a 3-year history
  • Proprietary prioritization algorithms rank order members based on the number of unidentified, undercoded diagnosis codes, type of codes, HCC & MLR changes, and revenue impact for chart reviews by the HCC coding analysts to maximize revenue with minimum member chart reviews
  • An easy-to-use, web-based application to significantly increase productivity for chart auditors and analysts, provide easy documentation for audit and compliance professionals and deliver premium transparency for senior management through the performance reporting tool

“Some of the biggest challenges faced are related to coding analyst productivity and premium revenue loss. The integrated workflows with embedded analytics helped increase our productivity by 25% and reduced our undercoding by 15%,” said Carey Ketelsen, Executive Director, GlobalHealth. “VitreosHealth organized data-driven risk adjustment process helped us increase our revenue capture by $2.5 million within the first six months.”

VitreosHealth also announced its first free State-of-Health Analysis (SOHA) to identify undercoding opportunities within a Medicare/Medicaid population cohort to establish a baseline for its pay-for-performance, outcomes-based pricing model to its customers.

“We believe the VitreosHealth solution is 3-4 times better than any solution in the marketplace in identifying opportunities,” said Jay Reddy, CEO of VitreosHealth. “By offering free assessments with an outcomes-based pricing model, we are putting our money where our mouth is.”

For more information on the VitreosHealth Predictive HCC Adjustment solution and the Pay-for-Performance program, please contact VitreosHealth.

About VitreosHealth

VitreosHealth offers the first Insights-as-a-Service delivery model for advanced population health analytics. They leverage Big Data and predictive and prescriptive health insights for population risk models that provide a complete view into the healthcare continuum. Their adaptive insights achieve a patient-centric focus for each perspective within a healthcare organization that leads to quality health outcomes and improves financial performance for a measurable return on investment.

VitreosHealth was recently awarded Frost & Sullivan’s 2016 North America Award for New Product Innovation for Advanced Population Health Analytics Solutions.

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Valerie Shropshire
since: 01/2014
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