Case Studies

Detailed review also led to identification of several other errors such as wrong patient coding, deleted codes, patient name mismatch among others.

 

Case Studies

 

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THE PROBLEM

  • Leading health insurance company faced with high error rates in HCC coding done internally / outsourced to an external vendor (not VRCM)
  • Client is looking to maintain high accuracy standards while minimizing cost
  • Missing / truncated HCC codes significantly impacts plan’s ability to receive funding reflective of the member’s full disease burden

On account of its Consistent track record of delivering 95%+ Accuracy, VRCM was selected as an audit partner

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THE SOLUTION

  • VRCM audited ~50K medical records, selected based on a random sampling done by its client
  • With 50K audited records, the Company identified errors in 5K records which equates to a 10% error rate
  • Identified 8,105 new revenue generating HCC codes, not captured earlier
  • Detailed review also led to identification of several other errors such as wrong patient coding, deleted codes, patient name mismatch among others
Error Classification Count
Missed HCC 8,105
Codes Deleted 267
Wrong Patient Coded 45
Wrong Bucket 40
Codes Changed 40
Date of Service Error 20
 
 

How Accurate HCC Coding Affects Risk Profile?

 

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Patient Profile -

Vascular complications and chronic heart failure (CHF), as well as other comorbidities

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Risk Adjusted Payment
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~200% increase in payments with all conditions coded as compared to missing HCC codes for chronic conditions