Medicare Advantage Plan Identifies Unrealized Reimbursement with NLP-Powered Second Level Review

Despite having 98% coding accuracy and undergoing two rounds of reviews by two separate coding vendors, a leading health plan decided to pilot a new coding solution from Episource—and unlocked an additional $43/chart.

The health plan was contracted to a third party for their submissions but they were growing dissatisfied with their vendor’s lack of flexibility to make customizations to the platform and execute them in a timely manner. The plan knew that greater insight into their data and control over the process was necessary. They required accurate and compliant submissions as well as a customer service team who was accessible and could quickly adapt. “We wanted more transparency and better support [for] what was going on with our records and our submissions to CMS,” said the plan’s Encounter Analysis Manager.

The Challenges:

• Maintain or Reduce Rejection Rate
• Improve Transparency
• Revenue Control

Download the case study to learn more about Episource’s approach and the solutions that were implemented to drive results for this large Puerto-Rican based Medicare Advantage health plan.