A complete, accurate risk score is key to optimizing revenue in the many markets in which you participate—from provider shared-risk deals to the Affordable Care Act (ACA), Medicare Advantage, and Medicaid markets. Reporting even a small difference in risk score from its true value can transform an otherwise profitable book of business into a losing proposition. Unfortunately, not all medical conditions affecting enrollee risk scores are properly identified (and some are completely missed), leaving your revenue out of line with your true level of risk. You need to perform all the necessary steps to optimize your risk score and reap the benefits that come with it.
How can you accomplish that? Increase the accuracy of your medical coding and condition identification through a robust statistical model. Milliman’s Integrated Medical and Pharmacy Record Optimization and Validation Engine (IMPROVE) combines your detailed claim and enrollment information with a proprietary algorithm to uncover opportunities to investigate undocumented or unsupported conditions or encourage enrollees to schedule annual wellness visits.
What makes our approach different? We combine multiple healthcare and demographic markers to isolate your enrollees with the highest likelihood of having a condition missing in your medical claim data. And, unlike other solutions currently on the market, IMPROVE provides a detailed assessment of the enrollee, the suspected condition, and the expected financial opportunity, allowing you to create a prioritized action plan for organizing and deploying your limited resources. Milliman specializes in analytics and analysis, and we strive to empower you by providing all the necessary information to make informed decisions.
IMPROVE can assist with any of your risk-adjusted populations. The graphic below demonstrates how IMPROVE identifies conditions and evaluates the financial impact, using the commercial ACA market as an example.
Example ACA IMPROVE Marker Summary – John Smith
| Predicted HCC
|
Predictive Marker
|
Marker Type
|
Probability Contribution
|
| HCC012 |
Tamoxifen Citrate |
Pharmacy |
46% |
| HCC012 |
Computer DX mammogram add-on |
Medical Procedure |
13% |
| HCC012 |
Carcinoembryonic antigen |
Medical Procedure |
11% |
| HCC012 |
Hematology/oncology: 1 or More Visits |
Specialist |
6% |
| HCC012 |
Ct thorax w/dye |
Medical Procedure |
5% |
| Total |
|
81% |
| HCC012 Value |
|
$6,800 |
| Final Expected Value |
|
$5,500 |
IMPROVE arms you with valuable information and insights, guiding the efforts and decisions that will help you stay ahead of the coding curve. Optimize your risk score and reap the benefits!
