Risk Adjustment Accuracy: General Gaps Analysis

Client Challenge:

Our client, a health plan serving dual-eligible D-SNP members, was concerned about the year over year accuracy of claim coding for chronic conditions, and variations in coding patterns for different provider groups.

Our Solution:

• Cirdan created reports to help our client identify potential gaps in their RAPS and EDPS data
  • The reports compared diagnosis coding for chronic conditions for successive years, to identify members for whom conditions reported in prior years were no longer reported
  • The reports also identified the specific claims where chart review would be appropriate
• The client used these reports to conduct chart audits to determine if coding was complete for the member
• Based on the chart audits, the client was able to identify diagnosis codes to be added or deleted for Medicare members

The Result:

By submitting additional diagnosis that were supported by the chart audits, the estimated impact on the clien’ts revenue was an increase of over $10 PMPM.