How Health Plans Can Use Analytics to Close Coding Gaps to Improve Care and Boost Revenue | Geneia

How Health Plans Can Use Analytics to Close Coding Gaps to Improve Care and Boost Revenue

August 17, 2016
Mark A. Caron, CHCIO, FACHE / Chief Executive Officer, Geneia


Health plans with Medicare Advantage (MA) programs are unnecessarily losing substantial revenue and missing care opportunities due to inaccurate, incomplete and untimely coding practices. The Centers for Medicare and Medicaid Services (CMS) reimburse Medicare Advantage plans based on each member’s health. Recorded disease and condition codes heavily influence the determination of health.

Correct diagnostic coding is one of the only ways a health plan can increase MA revenue, yet coding errors are the norm and health plans direct relatively few resources to develop effective proactive strategies. Consider the resources spent on disease and wellness programs, valuable components of modern healthcare, the best of which garner around $360 in savings per member per year. Comparing these savings to the approximately $2,000 per MA member per year return on improving coding practices reveals a deep disparity in spending and a high tolerance for errors.

The proper coding of disease and conditions is a struggle for health plans. Many turn to expensive outside vendors to review patient records and attempt to close coding gaps. This lengthy, retroactive process, which recovers a small fraction of the premiums, means lost revenue opportunities (as missing codes are still unknown), and capital that would otherwise be in the health plan system is tied up for another year.

There is a better way.

Health plans can leverage technology and approach coding from a holistic perspective, viewing the coding process as a tool for helping member populations in addition to capturing disease and condition data for proper reimbursement. By integrating ongoing detection of missing and suspect codes, health plans can:

  • Identify and prioritize opportunities for delivering services and capturing codes throughout the year.
  • Reveal charts worth tracking on a regular basis, greatly reducing the end-of-the-year scramble and inevitable coding errors.
  • Develop and implement a strategic approach to accurate, complete and timely coding practices.
  • Improve care outcomes and optimize revenue opportunities.

Accurate reimbursement enables health plans and providers to provide appropriate services.

Without proper reimbursement, the health plan bears the cost burden for services delivered. From a quality perspective, members with complex or chronic conditions, who have fallen through coding gaps and who are not identified as needing services, might not receive the medical care they require. Additionally, they are not being added to patient registries or enrolled in disease management programs. Lacking services, members in poor health and with complex conditions will likely suffer as their health deteriorates, potentially leading to expensive and avoidable complications. Without connections to primary care providers or care coordination, these members tend to rely heavily on expensive and disjointed emergency services for their growing care needs.

Download our coding gaps whitepaper now for valuable insight on how health plans can leverage analytics to improve care outcomes while boosting their Medicare Advantage Revenue.


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