Strategy and Solutions
The client is a regional Medicare Advantage (MA) health plan serving over 450,000 seniors. Operating in a regulated reimbursement environment, accurate RAF scoring is critical for financial performance. However, fragmented data and documentation gaps led to under-reporting under the V28 model. To address this, the plan partnered with Zymr to modernize its risk adjustment processes.
The health plan’s risk adjustment processes were constrained by fragmented data systems and manual chart review workflows. Critical patient information was spread across 142 different source systems, making it difficult to identify missed diagnoses and coding gaps.RAF under-reporting under the V28 model resulted in significant revenue leakage, estimated at over $18M. Clinical documentation inconsistencies and limited visibility into historical patient data further impacted accurate HCC coding.Provider engagement was also a challenge. Care teams lacked timely insights into documentation gaps, making it difficult to close care and coding gaps during patient interactions.The organization needed a unified platform capable of consolidating data, identifying risk adjustment opportunities, and enabling proactive provider outreach.
Zymr helped the health plan transform its risk adjustment process into a data-driven and proactive system. By leveraging advanced analytics and NLP-driven insights, the organization improved coding accuracy, enhanced provider engagement, and recovered significant revenue.
Zymr implemented a scalable RAF optimization framework combining data consolidation, AI-driven insights, and provider engagement workflows.
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