Case Study: a regional Medicare Advantage health plan improves RAF scores by 14% and recovers $22M with Zymr

a regional Medicare Advantage health plan improves RAF scores by 14% and recovers $22M with Zymr

A regional Medicare Advantage health plan serving over 450,000 seniors faced significant revenue leakage due to under-reported RAF scores under the new V28 model. This was caused by fragmented data across 142 different source systems and manual processes, which led to documentation gaps and missed diagnoses. The plan partnered with Zymr to modernize its risk adjustment processes.

Zymr implemented a scalable RAF optimization framework that included a unified data lakehouse and NLP-driven insights to identify missed diagnoses. This solution provided advanced analytics for gap detection and enabled proactive provider outreach. As a result, the health plan improved its RAF scores by 14% and recovered $22 million in revenue in the first year, while also significantly increasing its Star Ratings.