Strategy and Solutions
The client is a regional Medicare Advantage plan serving a diverse population with complex clinical needs. The organization struggled with under-coded member risk scores, which resulted in lower risk-adjusted reimbursements from CMS. Limited visibility into clinical data and lack of integrated systems made it difficult to capture the full burden of patient conditions. To address this, the plan partnered with Zymr to optimize RAF score accuracy and improve revenue outcomes.
The health plan faced persistent challenges with under-coding, where documented diagnoses did not fully reflect members’ clinical conditions. This gap led to reduced risk-adjusted payments and financial losses.
Data fragmentation was a major issue, with clinical, claims, and lab data spread across multiple systems, making it difficult to generate a comprehensive member view. Without integrated insights, identifying coding gaps required significant manual effort and was prone to errors.
Additionally, the absence of advanced analytics limited the plan’s ability to proactively identify high-risk members and ensure accurate documentation. Compliance with CMS requirements and timely submission of accurate data further added to operational complexity.
The organization needed a scalable, data-driven solution to improve RAF accuracy, streamline workflows, and maximize reimbursement while maintaining compliance.
Zymr enabled the Medicare Advantage plan to implement a robust RAF optimization solution that improved coding accuracy and financial performance.
Zymr developed and deployed a comprehensive RAF score optimization solution leveraging advanced analytics and integrated healthcare data.
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