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Case Studies   |   7.27.17

Apixio & Magna Health Plan

Increasing Transparency with HCC Profiler - Code Validation

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Fast Facts

  • 40,633 lives reviewed
  • 2,755 HCC deletes found
  • 95.3% agreement with deletes

About the Plan

  • Large health plan in the southwest
  • 12 years in Medicare Advantage
  • Serves four million customers in total

 

About the Project

  • Identified deletes by examining MA charts and claims-based HCC data
  • PDF charts processed
  • 584 score-impacting HCC deletes found
  • 2,171 non-score-impacting HCC deletes found
  • Following this project, Magna Health Plan engaged Apixio for three second-level review MA projects and code validation in 2017

A Crisis of Transparency

Recently, Magna Health Plan (MHP) decided to elevate their compliance efforts. They were worried that their reliance on vendors and outside coding help would compromise the accuracy and integrity of their risk adjustment results in a time of heightened scrutiny and pressure.

Achieving Gold Standard Compliance

Apixio offered several options for finding deletes. First, Apixio could do due diligence on the work of MHP’s previous risk adjustment vendor with “Compliance Auditor.” Second, in the process of examining select charts for new HCCs, Apixio could also check for evidence of previously submitted HCCs with “Zero Evidence.” Lastly, Apixio could look through all charts and seek to validate all previously submitted claims and new HCCs against the original source encounters with “Code Validation.” MHP chose the “Code Validation” option, seeing it as a truly comprehensive way to find deletes and enable a risk adjustment program that could look both ways.

 

Partnership Built on Trust

Risk adjustment is often fraught with difficulties, but the Apixio team built trust with the MHP team through key interactions. For example, early on MHP delivered a batch of duplicate charts, and the Apixio team highlighted the error, saving the client unneccessary billings and wasted time. Judy Beckenbach, their dedicated Customer Success Manager, ensured the project went smoothly and that any issues that arose were understood and handled.

Chart Quality Issues Reveal Strength of Apixio’s Platform

 

  • Charts were delivered to Apixio by the incumbent vendor with serious quality deficiencies (pages out of order, upside down, unreadable)
  • The Apixio platform used optical character recognition to rapidly decipher these difficult charts
  • Charts that might have been thrown out or overlooked were examined comprehensively
  • Apixio gave feedback to MHP on ways in which the chart pull process could be streamlined and improved
Testimonial
Judy
“It was a joy to work with Magna Health. They were committed to risk scoring accurately, and we were committed to serving them with the same level of integrity.”
Judy Beckenbach
Customer Success Manager
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Author
Andrew Raymore