India's largest platform and marketplace for AI & Analytics leaders & professionals

Sign in

India's largest platform and marketplace for AI & Analytics leaders & professionals

3AI Digital Library

Gaps in Coding

3AI August 18, 2020

Leading healthcare insurance provider

Problem Statement

  • To identify any revenue leakage due to gaps in HCC coding and subsequent risk-adjusted payments that are based on each member’s HCCs
  • Business objective was to develop an analytics process to predict any gaps in coding/HCC at each member level to plug any revenue leakage

Analytics Led Approach

  • An advanced next-gen HCC Gaps in coding analytics solution was developed :
    • Leverages machine learning algorithms to predict and identify missing and suspected HCCs and ICDs at member level
    • Provides a detailed predictive score-based map of all potential coding gaps for a member in a calendar period
    • Enables effective coding corrections by focused targeting of provider for filling coding gaps and behavior modification

Business Impact

  • Creation of HCC/HHS-HCC output file with member level HCC/HHS-HCC codes in order to maximize capitated payments

Critical Success Factors

  • Ability to pro-actively segment and target less likely members to ensure increased completion rates Advanced process to identify potential coding gaps among MA member
  • Enabled targeted approach toward coding correction via provider
  • $3.8mn – $18.8mn worth of potential annual revenue leakage identification per 31,374 members (assuming acceptance of 10 %– 50% of identified gaps)

    3AI Trending Articles

  • Give AI a ‘positive’ spin: Google tells its scientists

    Google has reportedly been telling its scientists to give AI a “positive” spin in research papers. Documents obtained by Reuters suggest that, in at least three cases, Google’s researchers were requested to refrain from being critical of AI technology. A “sensitive topics” review was established by Google earlier this year to catch papers which cast a negative […]

  • Barco unveiled its largest global Centre of Excellence for software innovation and R&D in India

    Professional visualisation and collaboration technology leader Barco on Wednesday unveiled its largest global Centre of Excellence for software innovation and R&D in India. In keeping with the hybrid workplace model, the new facility in Noida is designed to enhance productivity and features a common lab area offering flexibility for expansion or addition of new labs. […]

  • Evolution of Biometric Recognition Systems with AI

    Featured Article: Author: Kiranjit Pattnaik, MiQ What are biometric recognition systems Biometric recognition systems are computer-based systems that use an individual’s physical characteristics, such as their fingerprint, voice, face or any other part of the body, to authenticate their identity and grant access to secure areas, systems, or services. They are used increasingly as an […]

  • Amazon, Microsoft, Google: Platform of choice for European cloud services

    Amazon Web Services (AWS), Microsoft, and Google are continuing to blot out European service providers as the platform of choice for European cloud services, according to a new report from Synergy Research Group. The report found that while the European cloud market has more than tripled over the past three years, European service providers have seen their […]