Accurate clinical documentation and compliance are essential for maximizing reimbursements and delivering quality care. One leading Blue Cross and Blue Shield plan serving over 115,000 Medicare Advantage members partnered with Episource to overcome significant data accuracy and coding challenges. This case study highlights the impressive results of their collaboration.

What You’ll Learn

• How Accurate Clinical Documentation Impacts Reimbursements: Understand the financial risks of under-reporting illness burdens and how accurate documentation can increase monthly reimbursements.
• Key Challenges in Achieving Compliance: Discover the common issues health plans face, including data gaps and provider coding errors that jeopardize CMS compliance.
• Episource’s Proven Solutions: Learn how Episource’s chart retrieval and NLP technology achieved a 95% coding accuracy rate and improved data integrity.
• Strategies for Long-Term Success: See how data insights can be used to enhance provider education and how a shift to prospective documentation improvement can reduce costly errors.

Key Challenges Faced with Accurate Clinical Documentation

• Data Gaps and Illness Burden Reporting: The plan struggled to ensure claims data fully reflected members’ health conditions, risking under-reporting that could impact financial reimbursements.
• Provider Coding Errors: Miscoding and missing diagnoses from provider claims created obstacles for CMS compliance and reimbursement accuracy.
• CMS Compliance Pressures: Adhering to stringent Medicare Advantage requirements without accurate clinical documentation posed significant financial risks.

Results That Make an Impact

• 95% Coding Accuracy Rate: Episource’s efforts led to consistently high accuracy, boosting CMS compliance and reimbursement reliability.
• Significant Financial Gains: Improved illness burden documentation resulted in higher monthly reimbursements, crucial for supporting members with complex health needs.
• Enhanced Provider Education: Data insights from Episource helped the plan educate providers on accurate coding practices, fostering long-term compliance improvements.

Access the Full Case Study

Gain valuable insights into how advanced analytics and expert coding interventions can transform your financial outcomes. Download the full case study to learn how Episource can help your organization achieve greater accuracy and efficiency in risk adjustment through accurate documentation.