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Value-Based Reimbursement

Value-Based Reimbursement Success Story

THE SITUATION

A large health system in the Midwest engaged Pareto Intelligence in an evaluation of the completeness and accuracy of encounter data for their Medicare Advantage (MA) delegated risk population, limited to members from only one of their health plan partners. Because most encounter submission processes exist within health plan operations, this health system looked to Pareto for guidance on gaining access to the necessary data to assess submission accuracy, as well as how to evaluate that data once it’s received.

THE SOLUTION

After collecting the datasets from the health plan partner, Pareto leveraged its Value-Based Reimbursement solution to conduct Payer Data Validation, which identifies and prioritizes data quality issues impacting final risk adjustment factor (RAF) scores for the performance year.

This approach included independently quantifying RAF by member for each dataset in order to uncover discrepancies throughout the encounter submission process. Beyond that, Pareto prioritized results based on the financial impact of each variance, as well as applied root cause algorithms to identify the source of data quality issues. The health system was then able to use this information to focus remediation efforts prior to the Risk Adjustment Processing System (RAPS) submission deadline.

THE RESULTS

For this Value-Based Reimbursement client, the identified data quality issues had a $1.5 million financial improvement impact, clustered into multiple root causes. Given that this evaluation only covered members from one health plan partner, we estimate the improvement opportunity is much larger across the full MA population. While the original assessment was focused on RAPS processes, this client has engaged Pareto to perform Payer Data Validation across all MA members for both RAPS and Encounter Data System (EDS) submissions.

The following data quality issues presented the greatest improvement opportunity:

$1.3B

scoreable encounters omitted from RAPS submissions

$1.75k

risk-adjusted diagnosis codes omitted from RAPS submissions

~$1.5M

in total identified financial opportunity

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