Large Regional ACO Improves the Accuracy of Risk Submissions With Pareto Intelligence’s Revenue Integrity Solution

The Pareto Revenue Integrity solution was deployed to complete a comprehensive evaluation of the health system's end-to-end encounter data quality, which identified $4.7 million in financial opportunity.

CHICAGO, Ill., October 2018—A large accountable care organization (ACO) and provider system in the southwest has realized significant financial improvements through implementation of Pareto Intelligence's Revenue Integrity solution for its Medicare Advantage (MA) population.

Last year, the health system engaged Pareto to evaluate internal encounter processes and the submission accuracy of their payer partners. Multiple data quality issues were identified by Pareto's Revenue Integrity solution and remediated, having a $4.7 million financial improvement impact.

End-to-end Evaluation of Encounter Data

"Pareto completed an end-to-end evaluation of encounter data processes—from patient visit through various payer partners and ultimately to regulatory submission," said Brandon Solomon, Vice President of Client Advisory and Business Development at Pareto Intelligence. "Our Revenue Integrity solution uncovered the root cause of identified issues and supported speedy resolution and resubmission to CMS in advance deadlines, leading to direct impact on their bottom line."

Pareto's Revenue Integrity solution independently analyzes data generated by providers, payer partners and CMS, and applies detailed encounter-level analytics to uncover data quality issues suppressing Risk Adjustment Factor (RAF) scores, impacting Stars scores or posing potential compliance risk. For providers in value-based MA contracts, it's important to take this proactive approach to reviewing and analyzing key processes that drive revenue performance, particularly those typically the payer's responsibility. Even 1% data degradation can result in $60 to $80 per member per year (PMPY) in lost revenue.

Complete, Accurate and Compliant Submissions

Beyond the potential revenue impact, CMS recently announced an increased focus on program integrity, particularly for the Medicaid market, which makes accurate risk capture and submissions crucial to maintaining compliance. Pareto's Revenue Integrity solution focuses on two-way evaluations—both under-reported risk and incorrectly captured encounter information—to achieve complete, accurate and compliant submissions.

"Pareto's Revenue Integrity solution can be used by both payers and providers; however, it's particularly effective for health systems and ACOs looking to evaluate coding practices of physicians, as well as manage processes occurring within the health plan that impact capitation payments," said Jason Montrie, President of Pareto Intelligence. "An end-to-end assessment ensures that all information collected at encounter is making it through to submission and acceptance by CMS without any errors."

With 2018 regulatory submissions for encounter data well underway for all regulated markets, now is the time to evaluate end-to-end data processes to ensure issues do not exist that are suppressing revenues or presenting compliance risks.

About Pareto Intelligence

Pareto Intelligence is a leading healthcare technology company modernizing the way health plans and providers succeed in value-based care. We deliver analytics, technology and advisory solutions to help our clients achieve complete and accurate revenue, communicate critical patient information seamlessly, activate clinical and claims data, and make more informed strategic decisions. Our solutions are supported by proprietary algorithms, predictive models, and advanced data science that have analyzed over $150 billion in claims and medical costs and identified more than $250 million in financial improvement opportunity. Through this, Pareto demystifies complex healthcare data, and delivers actionable insights to improve outcomes.

To learn more about Pareto Intelligence, visit

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