Medicare Advantage is in crisis. Health Sigma can help

CMS overpays MA plans by 4.9%
compared to traditional MA, $7B in extra
spend (source: MedPAC)

CMS has made substantial changes that
virtually eliminate MA profit margin

Net Result: MA payments to reduce by 3.12%

SigmaRA can increase MA revenue
by $65-195 PMPM

SigmaRA differentiators are

Proprietary member risk analytics
Proprietary lab and pharma analytics identifies missing medical HCCs
Gen-AI analyzes medical charts identifies missing HCCs

SigmaRA’s Gen-AI auto-coding analyzes
100% of medical charts to find missing
HCCs and dollars

Traditional Process
01

Select charts are sent for recoding

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02

Medical coders manually recode

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03

New ICD codes, if any, may or may not map to additional HCCs

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Key Process Gap:

  • Majority of charts are not reviewed
  • Leaves money on the table
  • Manual, slow and expensive
SigmaRA’s process
01

ALL medical charts are sent to Gen-AI auto-coder

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02

SigmaRA’s Gen-AI agent identifies charts and codes that map to additional HCCs

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03

Medical coders ONLY audit charts with new HCCs

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Key Benefit:

  • ALL charts are analyzed
  • Only charts with missing HCCs are reviewed & audited by coders
  • Fast, effective and efficient

Three key pillars
of risk adjustment

1. Diagnostic Phase:
Capability Assessment

  • Assess current RA capability maturity
  • Identify gaps and opportunities for improvements

2. Execution
Phase:
Analytics & Operational
Redesign

  • Proprietary analytics that identify missing HCCs from lab and pharma claims
  • Gen-AI agent that auto-codes medical charts and flags encounters with missing HCCs
  • Improves CMS reimbursement by $65-195 PMPM
  • Workflow to track activities and team performance

3.Compliance:
Mitigate Audit Risk

  • Analytics that identify both under and over representation of risk
  • Gen-AI identified HCCs automatically routed for auditor review
  • Analyze provider coding patterns
  • Educate and engage providers on coding best practices

Solution installed on plan’s servers or Health Sigma’s cloud – safe and secure

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Client
Testimonials

Synergen Health deployed AI driven, Underpayment Analytics from Health Sigma. The solution used readily available 835s and successfully identified significant underpayments very efficiently. The mapping of underpayment to contracts further made the appeals process easier.

Sunil Konda

Vice President, Product at SYNERGEN Health

CFMC leveraged Health Sigma’s proprietary AI Analytics Platform for claims analytics and contract benchmarking. Health Sigma played a key role in improving CFMC’s overall financial performance

Anthony Gutierrez

Head of Revenue Cycle, Community First Medical Center