AI tool helps Gateway Health boost accuracy, population health

Gateway Health Plan is adopting a tool that uses artificial intelligence to enable health plans and provider organizations to increase the accuracy of their risk adjustment programs.

The Pittsburgh-based insurer is working with AI vendor Apixio, which recently released its new HCC Auditor solution, to assess critical insights about its patient population to help boost the productivity and accuracy of its risk adjustment program.

A recent study from Apixio on coding accountability found 50 percent of health plan coders said their organization reviewed fewer than 10 percent of charts, putting insurers at financial and compliance risk. In addition, 85 to 95 percent of risk adjustment payments for Medicare Advantage plans are based upon diagnosis codes on encounter claims from hospitals and clinics; the remaining 5 to 15 percent comes from chart coding, says Mark Scott, chief marketing officer at Apixio.

Getting a complete picture of its members’ health is why Gateway Health Plan is contracting with Apixio, says Gabriel Medley, vice president of quality improvement and risk programs at Gateway.

The platform compiles unstructured text, analyzes it and makes it machine readable. Apixio’s AI platform then identifies and captures additional information, such as date of service, ICD code and provider type, and flows all the data into an application that gives coders the information they need to confirm the accuracy of their risk adjustment code submissions. Traditionally, coders would comb through dozens of pages of patient charts looking for supported risk adjustment conditions.

“We collect patient conditions and map to a risk score that is retrospective and informs the payment,” Medley says. “We’re trying to reduce costs; we have so many coders trying to extract data from charts, and we want to replace quantity for quality to understand the disease burden of a population. Artificial intelligence never gets tired, and it picks up information coders may not see.”

Over time, most decisions on risk adjustment will be automated, with fewer than 5 percent of charts being looked at manually, Medley predicts. “These tools will help us with population health and quality improvement.”

One of the reasons Apixio got the contract with Gateway Health is because Medley met the company five years ago when it was developing its initial risk adjustment application, HCC Identifier, and was intrigued with the way the technology was being applied in the space.

With Apixio, Medley is confident that Gateway Health is accurately capturing the disease states of its members.