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%

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    Schedule Demo

    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