Risk Adjustment Accuracy: General Gaps Analysis
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.
- 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
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.