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Risk-Score Accuracy Improvement & Submissions

Driving Economic Performance through Differentiated Advanced Analytics, Point-of-Care Solutions and Integrated Strategies

Accurately identifying opportunities for risk score accuracy improvement can be an immense challenge without the right resources. Whether you seek a comprehensive, end-to-end solution or one that will supplement your current program, Inovalon’s integrated solution suite is designed to maximize risk score accuracy and deliver accurate financial performance. Inovalon works in collaboration with our clients to design a program that delivers on desired ROI and overall financial goals.

Retrospective Risk Score Accuracy Improvement

Inovalon’s retrospective risk score accuracy solution identifies, pursues and documents valid diagnoses not otherwise properly or fully captured by a health plan’s primary claims systems–utilizing automated technologies like EHR interoperability or Clinical Data Extraction as a Service (CDEaaS™), as well as other forms of traditional paper-based medical records. Each of these gaps represents a potential inaccuracy between the “data picture” and the “true clinical picture” of the member. Leveraging proprietary clinical data-driven algorithms and predictive analytics, Inovalon customizes targeting of hierarchical condition categories (HCCs) based on unique membership characteristics and data elements. Upon identifying each risk score accuracy improvement opportunity, Inovalon generates and reports a financial analysis, verification probability, and an ROI threshold variance.

Inovalon’s nationwide network of highly trained clinical reviewers delivers comprehensive clinical record and case review expertise, all of which are enabled by professional project management and leading-edge EHR and paper-based medical record abstraction technology. With clinical data extraction and natural language processing capabilities that automate and accelerate the medical record retrieval and review process, health plans can reduce the need for on-site medical record review, resulting in reduced provider abrasion and greater operational efficiency.

Inovalon’s Natural Language Processing as a Service (NLPaaS™) leverages the Inovalon ONE® Platform’s highly adaptive machine learning capabilities along with data on billions of known medical events to transform unstructured clinical data into highly valuable, structured data, which are then analyzed at massive scale in fractions of a second. Employing state-of-the-art deep learning and machine learning algorithms, our natural language processing solution significantly decreases review time, enabling risk score-relevant condition detection 4 times faster than traditional methods and reducing the overall clinical review program spend by up to 25%.

Prospective Risk Score Accuracy Improvement

Utilizing advanced, cloud-based analytics powered by Inovalon’s ever-expanding proprietary dataset, including data pertaining to more than 278 million unique patients and nearly 46 billion medical events, and extensive EHR connectivity to more than 217,000 providers, our prospective risk score accuracy solution enables health plans to predict emerging patient-specific diagnoses and drive highly-targeted interventions for the right members, through the right venue, with the right clinical content, at the right time. Our extensive nationwide EHR connectivity enables access to the data of approximately one in every three patients in the United States, increasing speed-to-value for risk score accuracy improvement initiatives and decreasing provider abrasion by reducing the need to interrupt provider activities.

Leveraging our suite of point-of-care solutions, including in-office clinical documentation support that delivers 143% greater value compared to other vendor tools on the market, Inovalon translates resulting predictive analytic insights into impact – whether in a provider’s office, a retail clinic, or a member’s home. Inovalon delivers actionable insights to the point-of-care to address care gaps, patient assessment, and disease and comorbidity burden documentation and provide guidance for providers during patient assessments to drive gap closure.

RAPS, EDS & EDGE Server Submissions

Risk score accuracy begins with ensuring accurate claims and data submissions. With more than a decade of experience implementing effective data submission solutions—having never missed a CMS deadline—Inovalon delivers complete, accurate and secure submissions, on-time, every time. With dynamic impact tracking and reporting, health plans can proactively manage claims processing at various stages throughout the submissions process and monitor the financial impact of the claims in error or not submitted to ensure an accurate and timely submissions process.

Inovalon has an average acceptance rate of 98.3% across RAPS, EDS and EDGE Server submissions—an acceptance rate materially higher than many in-house solutions and third-party vendors. The improvement in submissions accuracy and acceptance rates translates into not only greater compliance rates but also improved financial performance, the elimination of duplicative processes, and more rapid achievement of financial transparency. Inovalon’s end-to-end submissions solutions support complaint, accurate HCC submissions, mitigating RADV risk and enabling health plans to avoid regulatory disciplinary action and ensure correct processes going forward.


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