Ejyle Healthcare Analytics & Risk Adjustment (eHARA)

Over the last few years the US government has come up with several programs to ensure the affordability and accessibility of healthcare for the population. Some of the well known programs are the Medicare, the Medicaid and the ACA Marketplace.

Considering that these plans (which are administered by Private health plans on behalf of the government), are funded typically by a Global Capitated Model, one of the greatest challenges facing such plans is the problem of Revenue Leakage which typically occurs due to certain health conditions which get missed while being reported to CMS (as part of submitted encounters).

The dire need is for a platform that can

  • Calculate Risk Scores Accurately
  • Identify Potential Gaps in Health Conditions for specific members with potential revenue impact
  • Provide a Targeted Chase List for Chart Reviews to plug gaps and enhance revenues
  • Ability to Forecast Potential Revenue Targets for future year

ejyle Healthcare Analytics and Risk Adjustment Platform brings in a combination of Rule Driven, Diagnostic, Predictive and Machine Learning Algorithms that addresses the numerous challenges facing Health Insurance providers. It is the ultimate AI-driven RAF solution to prevent revenue leakage, enhance efficiency and reduce cost:

  • FULLY AI-POWERED RAF SOLUTION
    A true AI-based Risk Adjustment Factor solution to adjust risk and prevent revenue leakage.
  • SIMPLE AND ACCURATE SCORE ANALYTICS
    Get a clear picture of risk stratification of the population based on known health conditions and potential predicted health conditions
  • CHASE STRATEGY AND CHART REVIEW ANALYSIS
    Clear chase prioritizations driven by potential revenue impact, probability of potentially missed conditions to convert to actual misses, recommended claims and providers to chase. Gap closure tracking based on processing Chart Reviews.
  • COMPREHENSIVE RAF GAP ANALYSIS
    Identify gaps up-front with multiple algorithms and multiple sources aiding the gap identification. Identification of suspect members and missed conditions
  • MULTIPLE DESCRIPTIVE, PREDICTIVE AND FORECASTING MODELS
    Numerous drilldowns by members, health conditions, providers, risk levels, co-occurrence including Financial Forecasting and Target Revenue Planning, Health Conditions Prediction for future, Forecast of Provider level Claim volumes, member visits, Utilization Analysis, Planning for Wellness Campaigns for Co-occuring Health Conditions.

CHALLENGES

Accuracy

Gap Analytics

Forecasting
& Optimization

One Platform

MODULES

RISK SCORE CALCULATION
Ability to identify high risk members/conditions

GAP ANALYSIS
Identify suspect members/Gaps in coding & revenue impact validated by ML based probability models

CHART REVIEWS
Analyse the impact of chart reviews on RAF Score

FINANCIAL FORECASTING
Financial forecasting of RAF and revenue for future year

SERVICE UTILISATION
Ability to view Cost/Utilisation against revenues

ML DRIVEN PREDICT ALGORITHMS
To predict potential health conditions

SOLUTIONS

EFFICIENT RAF SCORING

DEEP GAP ANALYSIS
& INSIGHTS

FINANCIAL FORECAST
& UTILIZATION VIEWS

ADAPTABLE TO ANY MODEL/MARKET

Revenue Increase

  • Executive Level visibility to Revenue Forecasting and managing Risk Advantage Markets
  • Proactive Prevention of Revenue Leakage by identification of coding gaps at a claim level
  • Retrospective Revenue Enhancement through follow ups on Chase Lists

Target With Greater Accuracy

  • Focus to target by Providers & Members to optimize chart reviews that can increase risk score diagnosis reporting
  • Focus on reducing avoidable service for high utilization members

Single Platform For All LOB’S

  • Customized & refined Learning models based on provider coding patterns, membership utilization patterns for all Lines of Business

Early Identification Of Gaps

  • Proactive Machine Learning models that track coding gaps as early as claim processing encounter submissions
  • Proactive Prevention of Revenue Leakage by identification of coding gaps at a claim level

Additional Benefits

  • Identification of high risk members that need specific proactive care and wellness campaigns
  • Identification of high utilization members where avoidable services can be focused upon
  • Inputs for Population Health Management Programs
  • Provider engagement programs to enhance awareness on coding related issues