Government Business

How do we solve this problem?

Regarding capabilities in in terms of incorrect Medicare Advantage payments, HiLabs offers an unguided AI solution to detect up-coding in Medicare Advantage. The tool MSure, performs comparative data quality and completeness of MA data analysis and has been customized on medical ontologies based learning to fine tune for Risk Adjustment.
MSure has found potential overpayment of $80M in just one state (FL) and around $14M in ER visits for a large health plan in the first quarter of 2020.

In the “capability to assess business impact due to policy changes” space, HiLabs offers MVision, a what-if-analysis capability that executes impact analysis and gives production advisory. The tool gives the flexibility to try-out various options of HCC modeling, powerful and scalable "what-if" analysis capabilities and also an accelerator to build big data (Hadoop/Spark) based RASS for CMS. With this tool, users can identify average impact on RAF score (and associated dollar amount), visualize impacts, identify net scoring of HCCs and carry out impact analysis at beneficiary level.

Business value provided to the client by-


  • Having an interactive user configurable logic to define variables related to interactive diseases

  • Allowing users to identify multiple metrics like-

    • Average impact on RAF score and associated dollars
    • Visualize/drill-down RAF/dollars impact by various parameters related to beneficiaries
    • Net scoring of HCCs based on number of beneficiaries
    • Impact analysis at each beneficiary level

  • Correct Disease hierarchy implementation by including data elements related to HCC coding and Risk Adjustment Modeling

  • Additionally, leveraging MCheck’s capability in RASS data validation where it offers a scalable and easy to maintain solution that can be easily plugged into input/output points of the overall process

Interactive Variable Configuration

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Example of customized parameters while running a model for RAF scoring

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Impact analysis

Pre-configured Hierarchies of HCCs

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