India's largest platform for AI & Analytics leaders, professionals & aspirants

Sign in

India's largest platform for AI & Analytics leaders, professionals & aspirants

3AI Digital Library

Gaps in Coding

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

  • ISRO Regional Academic Centre for Space at IIT-BHU

    IIT-BHU director Prof P.K. Jain said that the RAC-S will act as a major facilitator for promoting space technology activities in the states of Uttar Pradesh, Madhya Pradesh, and Chhattisgarh. VARANASI: The Indian Space Research Organisation (ISRO) will set up its Regional Academic Centre for Space (RAC-S) at IIT-BHU here. A memorandum of understanding (MoU) […]

  • Cloud Neutrality

    A multibillion-dollar, privately-owned infrastructure is now essential to the modern internet economy. That should freak you out. WE SPENT A lot of years talking about net neutrality—the idea that the companies that provide access to the internet shouldn’t unfairly block, slow down, or otherwise interfere with traffic even if that traffic competes with their services. But there’s […]

  • HCM Decision Making powered by Talent Sciences

    Talent Science is the business capability of using advanced data analysis techniques and predictive models to drive HCM decision making. It calls for a logical connection between decisions about people, HR program investments and strategic business outcomes. This can form a backbone of human resource function of all organizations independent of the sector in which it operates. […]

  • Mindtree achieves Application Development Partner Specialization in the Google Cloud Partner Advantage Program

    Mindtree on Monday announced that it has achieved the Application Development Partner Specialization in the Google Cloud Partner Advantage Program Technology services company Mindtree on Monday announced that it has achieved the Application Development Partner Specialization in the Google Cloud Partner Advantage Program. “This specialization highlights Mindtree’s expertise and success in building customer solutions in […]