Case Study: a regional Medicare Advantage plan improves RAF accuracy and recovers $22M with Zymr

Regional Medicare Advantage Plan improves RAF scores by 14% and recovers $22M with Zymr

The customer, a regional Medicare Advantage plan, struggled with under-coded member risk scores due to fragmented clinical data and a lack of integrated systems, leading to lower reimbursements from CMS. To address this challenge and improve revenue outcomes, the plan partnered with vendor Zymr to optimize its RAF score accuracy.

Zymr implemented a comprehensive RAF optimization solution that included a unified FHIR-based data platform and AI-driven predictive models to identify coding gaps. This provided clinical evidence-based insights and streamlined workflows for the customer's coding teams. As a result, Zymr enabled the plan to achieve a 14% improvement in RAF scores across its target population and recover $22 million in revenue within the first contract year.