Systems and methods for determination of patient true state for risk management

Abstract

Systems and methods for managing audit risks utilizing the true state of the patient are provided. A number of medical records for a patient are subjected to predictive modeling for various conditions (known as patient 'true state'). The true state is then cross referenced by the eligible Medicare documentation, and any findings that are being submitted to MediCare for reimbursement. The result of this cross referencing is the ability to classify each finding and/or true state into a 'green, 'yellow', or “red zone'. The green zone is where the finding, documentation and true state are in good alignment. A red zone is where the finding and the true state are entirely at odds. The yellow zone is where the findings and the true state are in agreement, but where there is still audit risk that may be resolved through one or more “opportunities”. Examples of opportunities include bolstering the documentation for the reimbursement, getting additional evidence to improve the confidence of a true state inference, or including additional documentation for a finding that exists in the true state, but hasn't been previously identified.