Case Study: Regional Health Plan achieves $357,000 annualized HCC gain with Optum's AI-driven MA chart recoding and reprocessing

Chart Recoding and Reprocessing Yields Substantial Gain

Regional Health Plan engaged Optum to address underestimated Medicare Advantage risk scores caused by missed hierarchical condition categories (HCCs). The plan asked Optum to retrospectively review a sample of 147 MA members using an AI-driven coding solution to detect missing or underdocumented chronic conditions and ensure appropriate risk-adjustment scoring.

Optum’s team deployed AI, natural language processing, and machine learning to reprocess roughly 1,000 charts and identified $30,291 in new or additive HCC value—about $357,000 when annualized—representing a 20%–30% improvement over the incumbent’s manual HCC reviews. With Optum’s documentation, the plan was able to resubmit supplemental encounter data, boosting near-term revenue and improving ongoing risk-score accuracy.