Case Study: a small- to medium-sized health plan improves risk scores and CMS reimbursement with EXLCLARITYTM from EXL

Retrospective risk recapture powered by EXLCLARITY™

EXL worked with a small- to medium-sized health plan in the southeastern United States that had about 10,000 Medicare Advantage members and needed better visibility into CMS risk scores and HCC gaps. The customer lacked in-house analytics to identify high-value members for chart review, needed support for retrospective risk recapture, and wanted data extracted in a customized format for CMS submission.

EXL implemented and configured its EXLCLARITY risk adjustment platform to analyze claims, labs, eligibility, and CMS files, support chart reviews, create targeted member outreach lists, and provide Tableau dashboards and custom reporting. EXL also enabled claim-level diagnosis editing and ROI tracking, helping the health plan improve member risk scores by 11%+ in 2019 and 20%+ in 2020, while identifying additional revenue opportunities of more than $120K in 2019 and $3M in 2020.