Failure to Implement More Efficient Risk Adjustment Methods Puts Medicare Advantage Plans at Risk for up to $16.2 Billion in Potential Errors
San Mateo, Calif. –December 18, 2017 – Apixio Inc., the data science company for healthcare, is enabling healthcare organizations across the country to gather a more accurate picture of actively treated patient diagnoses. Apixio’s proprietary artificial intelligence platform helps insurers audit their data for accuracy with less time and cost, by using machine-based analysis of hospital, clinic and provider-based medical records. For providers and insurance plans striving to meet more stringent audit requirements from Medicare, there is a widespread recognition that technology will be part of the solution. This is a trend that is demonstrated by Apixio’s rapid growth; in the past year alone, the company analyzed 89% more medical records than the year prior, and they now boast 33 customers, including 5 national health plans and 9 Blue Cross Blue Shield Association plans.
“The volume of health records that need review is well beyond what coders can manage on their own. With increased risk adjustment payment scrutiny, there is a great demand for technology to augment the process of reading and deciphering medical records for disease data,” said Darren Schulte, MD, CEO, Apixio. “We have proven that machine learning can help coders find more in medical records than they would alone. As a result, our solutions are in much greater demand in the marketplace.”
Artificial Intelligence for Federal Risk Adjustment Compliance
The lack of accuracy in data used for risk adjustment has drawn the attention of Medicare and the Department of Justice, as the Government Accountability Office (GAO) has estimated a roughly 10% improper payment or error rate in Medicare Advantage reporting — that’s more than $16.2 billion per year. If health plans fail to implement a more accurate method, the cost of error will continue to rise along with Medicare Advantage enrollment, which is expected to grow from 33% to 41% of all Medicare beneficiaries by 2026.
“Health plans are striving for greater accuracy in their chart review and risk adjustment processes than ever before. However, traditional coding processes are no match for today’s increasing workloads and strict industry standards,” said James P. (Jim) Bradley, Board Chairman, Apixio. “As the industry works toward a value-based healthcare system, technology solutions are key to meeting high volumes and industry demands for accuracy.”
Apixio Solving Risk Adjustment with Intelligent AI-based Solution
Apixio’s HCC Validation solution helps organizations achieve unprecedented accuracy for Medicare Advantage and commercial risk adjustment. Apixio’s algorithms uncover documented evidence of HCCs within hospital and clinic charts and compare these results to codes previously reported to Medicare. Those HCCs without sufficient evidence, as determined by the algorithms and agreed upon by professional coders, are presented to the health organization for removal from use in risk adjustment payment calculation.
This process results in risk adjustment submissions that can be confirmed as accurate with a high degree of certainty. To learn more about how Apixio’s solutions are helping healthcare companies achieve this standard, visit: https://www.apixio.com/solutions/.
Apixio, the data science company for healthcare, develops AI-based analytics to enable novel insights from both medical text and codes for improved healthcare delivery. Apixio’s HCC Profiler leverages its proprietary algorithms and platform to help coders achieve unprecedented accuracy and efficiency for risk adjustment. The Apixio algorithms are based upon learning from more than 600 million clinical documents.