Risk Adjustment has fundamentally changed the economics of Medicare managed care. Plans no longer need fear the havoc adverse selection wreaks on their bottom line, provided they have a good grasp on HCC coding. Does yours?

Medicare Advantage plans are currently leaving millions of dollars on the table due to incorrect or incomplete Hierarchical Condition Category or “HCC” coding. With risk adjustments on payments now at 100% (having risen incrementally over the past three years, aggressive management of HCC coding is imperative in order to maintain revenues and profitability.

Leprechaun is a turnkey HCC management system employing next generation neural networks and artificial intelligence technology to identify incorrect patterns in provider coding. But Leprechaun is more than just software. Other products on the market find money. Leprechaun brings it home. The technology is complemented by tailored, flexible consulting and intervention services to help ensure the plan capitalizes on its coding opportunities.

The Implications

How it works

By “crosswalking” existing clinical and pharmacy claims data (at a minimum), Leprechaun identifies members who have coding inaccuracies and even more importantly, identifies the providers who are persistently getting it wrong.  We then employ a physician-staffed call center (because doctors only listen to other doctors!) to re-train physicians, as well as a team of certified coders to conduct on site chart reviews.

Finally, we help you recover the appropriate reimbursement from CMS by providing you and CMS with the data and detail needed to support the appropriate payment level, within mandated timelines. Most importantly, Leprechaun is designed to prospectively mitigate the problem of inaccurate coding, so that the risk-adjusted revenues are captured upfront.

For more information or to schedule a private demonstration, please email us at leprechaun@gormanhealthgroup.com or contact Nathan Goldstein at (202) 364-8283.