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Data Integrity: Medicare Advantage

Data Integrity Success Story: Medicare Advantage

THE SITUATION

A 100,000-member MA plan was achieving a 99.5% submission and acceptance rate across both RAPS and EDS. The 0.5% in risk degradation resulted in a $3M suppressed risk transfer ($30 PMPY).

THE SOLUTION

The health plan engaged Pareto’s Data Integrity solution to evaluate end-to-end data quality and identify points of data degradation throughout the entire process—from encounter through to regulatory submission. Our solution works by obtaining data extracts from each point in the data process and applying advanced analytics to compare each dataset and determine the specific points of data leakage. Once discrepancies have been identified, the solution prioritizes gaps for remediation.

THE RESULTS

Pareto’s Data Integrity solution identified the following root causes of gaps in reported risk to focus remediation, resulting in $3 million in financial improvement opportunity:

$1.2 million

Scoreable claims never submitted to RAPS or EDS

$1.0 million

Scoreable claims never submitted to RAPS, mostly due to vendor inappropriately excluding anesthesiology claims

$660k

Unresolved EDS front-end errors

To maintain data quality year-round, ongoing monitoring is recommended for proactive identification of future challenges and quick resolution of issues in advance of deadlines. This client is utilizing Pareto’s Data Integrity solution to conduct ongoing periodic evaluations throughout the year to proactively identify and address data quality issues.

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