Value-Based Reimbursement
Value-Based Reimbursement Success Story
THE SITUATION
A health system with 40,000 Medicare Advantage (MA) members across multiple payers engaged Pareto Intelligence to evaluate internal encounter processes as well as the submission accuracy of their payer partners.
THE SOLUTION
Pareto deployed Payer Data Validation as part of its Value- Based Reimbursement Solution to complete a comprehensive evaluation of end-to-end encounter data quality and submission accuracy.
Using this solution, Pareto independently evaluates 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 and/or posing potential compliance issues.
THE RESULTS
For this client, multiple data quality issues were identified throughout the process and remediated, having a $4.7 million financial improvement impact.
Pareto’s clustering algorithms uncovered the primary root causes impacting revenue, enabling prioritized remediation efforts. Configured reporting led to speedy resolution and resubmission to CMS in advance of the submission deadline. The following data quality issues presented the greatest improvement opportunity: