Risk Adjustment

Is 95% Coding Accuracy Good Enough?

Written By
Erik Simonsen
Chief Operating Officer

Accuracy, efficiency, compliance—these are all qualities health plans aim to achieve in their risk adjustment programs. So, why is it that most plans only code medical records to 95% accuracy? Leaving even that 5% on the table could mean missing out on 25%+ of a chart’s potential value, not to mention the increased risk of being audited. In today’s challenging landscape of rising costs and growing compliance risk, 95% accuracy is no longer enough.


It’s become industry standard to code medical records to 95%. But would you be satisfied with receiving 95% of your paycheck each month? Or 95% of your retirement savings? Probably not. Yet many health plans currently accept a 95% coding accuracy rate.


Second level reviews are an excellent way for health plans to improve coding accuracy, but many do not currently utilize this strategy. Perhaps this is because traditional programs have typically been lengthy and manual processes that require a full duplication of work. The introduction of AI and NLP, however, has transformed the second level review into a more efficient and effective process—one that can help ensure risk score accuracy, mitigate compliance issues, and ultimately improve patient care.

To read the full article, visit RISE.


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