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Case Studies   |   7.7.17

Sigma Health Plan

Increasing Risk Score Accuracy with HCC Profiler - Code Identifier

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Fast Facts

  • 70,000 lives reviewed
  • 983 new HCC codes
  • 98.5% coding accuracy

About the Plan

  • Large health plan in a major metropolitan region
  • 100,000 total MA lives

About the Project

  • EHR and PDF charts processed
  • Apixio won business after successful five-week pilot
  • Formal project consists of first- and second-pass review of previously coded MA charts
  • In 2017, Sigma Health Plan used the HCC Profiler service to perform first-pass chart review for both their MA and commercial memberships

A Winning Pilot

Sigma Health Plan (SHP) commissioned five-week parallel pilots with Apixio and another vendor for a first-pass review of 200 medical charts. The Apixio team retrieved and analyzed the relevant data from Epic in under three-and-a-half weeks. SHP coders then completed their coding review of the charts using HCC Profiler, bringing the total timeline to four-and-a-half weeks. The other technology vendor under evaluation was unable to even extract the data within the five-week project timeframe. The Apixio team found 600 new supported HCC codes in the charts, a strong result that pleased SHP.

 

Formal Project Launch

SHP used HCC Profiler to do a second-pass review of charts for 63,679 MA members in SHP’s employed provider practice and a first-pass review of 5,505 MA members in its independent provider network.

A “Zero Evidence” report was presented, listing previously reported HCCs from the RAPS return file that lacked sufficient evidence in the submitted encounter notes.

Apixio worked closely with Sigma Health Plan’s risk adjustment director to sync the coding guidelines with the organization’s standards and ensure adherence by experienced and rigorously assessed coders.

983 new HCC codes and 177 potential deletes were delivered by Apixio in under 12 weeks – a pace unattainable without technology. SHP audited and agreed with 98.5% of the new codes. They agreed with 72% of the potential HCC deletes, despite Apixio’s handling only 70% of SHP’s total MA charts.

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Author
Andrew Raymore