Prioritize your optimization efforts with suspect analytics

How accurate are your risk scores? To ensure accurate premium payments that won’t get clawed-back in future audits, it’s critical that member risk scores accurately reflect their overall illness burden. Missing, incomplete or inaccurate diagnosis codes can negatively impact your individual member risk scores, but identifying which members have undocumented conditions can feel like finding a needle in a haystack.

Deeper Dive Analytics to Better Focus your Resources

Mile High Healthcare Consulting takes a big data approach to suspect analytics for Exchanges, Medicaid, and Medicare-Advantage. Our analytics help you prioritize members for retrospective chart review, in-home assessments, or provider office-based interventions. Our suspect analytics include more data sources than typically used to identify target conditions that require additional documentation. We commonly analyze the following sources to identify previously undocumented HCCs:

  • Prescription drug data, including drug regimens that are FDA-approved or used “off-label”
  • Quality measure compliance results
  • Historically occurring diagnosis codes
  • Clinical laboratory results
  • Provider continuity of care, during the measurement year and in prior years

At Mile High, we don’t believe in analysis for analysis sake, each project is designed and executed to yield specific financial or member process of care benefits for our clients.

Predictive Modeling to Increase Efficiency in All Lines of Business

We apply our predictive modeling capabilities to score and prioritize opportunities in all lines of business—commercial exchanges, Medicare-Advantage, and Medicaid managed care as seen below:

Operating a health plan in a value-based payment environment is increasingly complex. Risk adjustment and quality improvement is much more difficult for the commercial exchanges and Medicaid (fewer members get risk adjusted, interventions are harder to deploy, and quality measurement involves new populations, including children), but the premium risks are just as significant. That’s where Mile High Healthcare Consulting comes in. Our research and modeling helps you identify and prioritize opportunities for improving individual risk scores and better managing revenue. Opportunities can be prioritized by geography, provider group, disease category or other variables.

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