Case Study: Health Insurance Company in California achieves 23:1 ROI and $1.5M annual risk-adjusted revenue with SCIO Health Analytics

Health Insurance Company in California - Customer Case Study

Health Insurance Company in California, a 60,000+ member health plan, lacked visibility into whether risk-adjustable codes from inpatient stays were captured on claims. Rapid membership growth and members using hospitals for acute care rather than preventive services meant missing inpatient data threatened the plan’s risk score accuracy and CMS reimbursement. SCIO Health Analytics was engaged to address this gap using its SCIOClarity Inpatient Data Pursuit service.

SCIO Health Analytics deployed its full-service SCIOClarity™ Inpatient Data Pursuit to connect with hospitals and care facilities, capture additional or corrected codes from 100% of inpatient stays, and perform concurrent pursuits for timely CMS reimbursement. The effort delivered a 23:1 ROI, a 90% response rate within the first 90 days, an estimated $1.5 million annual value from additional risk-adjustable codes, and a more complete HCC data set to share with primary care providers.