Chart review program redesign for a regional MA payer.

A regional payer had conducted medical record reviews across its MA lines of business, following best practices by coding both adds and deletes. Despite this effort, a persistent performance gap remained between the plan and its competitors in risk score accuracy. Our review revealed that only half of the medical records suspected of open gap diagnosis codes were reviewed in the plan's retrospective chart review programs — resulting in under-coding and missed risk adjustment revenue opportunities.

Client profile

Regional payer started in 2019 with Medicare Advantage lines of business.

The challenge

• Ongoing gap in risk score accuracy compared to peers
• Limited scope of retrospective chart reviews leading to under-coding
• Concern about potential diminishing returns from expanding review volume

Our approach

• Analyzed historical results and applied advanced analytics to identify gaps in existing targeting logic
• Redesigned and expanded targeting parameters to capture a broader and deeper set of records
• Revamped the retrospective chart review program within one week to increase review scope and precision
• Balanced cost and return modeling to ensure the expanded program maintained strong economics

Results