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

  • Transforming Enterprises with a Generative AI Strategy

    Featured Article: Author:  Vijay Morampudi, Director, Wavelabs Technologies Generative AI has the potential to revolutionize industries as a whole. As a leader, it is crucial tocreate an effective generative AI strategy for your enterprise to stay competitive and take advantageof the technological advancementsThis article presents seven practical steps that can be followed to create a […]

  • Combining the power of Generative & Predictive AI

    Featured Article: Author: Shuvajit Basu GenAI has taken the world by storm. I certainly don’t have to outline the numerous possibilities it brings to bear. Both GenAI and Predictive AI have their share of strengths andbopportunities. However, if we can combine the power of these Generative models with Predictive AI/ML models, we might be able […]

  • Property Registration in Karnataka to use Blockchain Technology

    Property registration in Karnataka is all set to become more secure and hassle-free, with the state government developing a system based on blockchain technology for online property documentation. The new system, developed in collaboration with IIT-Kanpur, promises an immutable electronic storage of property data through blockchain. In other words, data once stored cannot be changed, […]

  • 2 Transportation related Stocks leading the New Wave with AI

    Technology is changing our world, with results visible in real time. If you grew up in the 1980s, watching reruns of Star Trek, think for a moment about fantastic gadgets that have walked off the screen and into our lives: portable communicators, portable computers, voice-activated systems, to name just a few. Scotty once even automated […]