MEDICARE ADVANTAGERISK ADJUSTMENT
Regional MA plan lifts HCC recapture from 81.4% to 90.6% over 18 months
A Pacific Northwest MA plan with ~180,000 members was hitting a recapture ceiling on its prospective program. Lumiknox stood up a concurrent-coding pod within 30 days, integrated suspect lists with the plan’s in-home assessment vendor, and added retrospective second-level review. Result: 9.2-point recapture lift, with an audit defensibility score consistently above 96%.
+9.2ppRecapture Lift
18moEngagement
96%Audit Defensibility
TPACLAIMS PROCESSING
Mid-market TPA pushes first-pass adjudication from 78% to 91% in six months
A TPA serving 240+ self-funded employer groups was stuck at 78% auto-adjudication on a HealthRules platform. Lumiknox deployed edit-resolution agents and ran a parallel configuration audit. The combined effort closed 13 percentage points in six months and reduced cost-to-adjudicate by $8.20 per claim.
+13ppAuto-Adj Lift
-$8.20Cost/Claim
6moEngagement
IDNDENIALS & APPEALS
Eight-hospital IDN reduces denial backlog 74% with agentic appeals
An eight-hospital integrated delivery network was carrying a denial backlog north of 22,000 claims. Lumiknox deployed an agentic appeals workflow with credentialed reviewer escalation, working overnight cycles in Manila. The backlog dropped 74% in 90 days, and overturn rate on appealed denials rose from 41% to 58%.
-74%Backlog
58%Overturn Rate
90dTo Steady State
MEDICARE ADVANTAGEHEDIS & STARS
MA plan moves from 3.5 to 4.0 Stars with targeted gap-closure program
A Midwest MA plan needed to recover Star Rating to protect its CMS bonus payment. Lumiknox built and ran a member-level gap closure program covering 14 measures, with bilingual outreach and provider engagement. The plan moved 0.5 Stars in a single MY, including a 28-point CMR completion lift and meaningful CAHPS movement.
+0.5Star Rating
+28ppCMR Completion
14Measures Worked
MEDICAID MCORADV
Medicaid MCO defends contested RADV findings, recovers $4.1M in disputed payments
A state Medicaid MCO received a RADV audit notice with material extrapolated findings. Lumiknox built the defensibility record — chart-by-chart, documentation citation-by-citation — over a 120-day response window. Of $6.8M in initial contested findings, the MCO retained $4.1M after appeals.
$4.1MRetained
60%Overturn Rate
120dResponse Window
AI/ML ANALYTICS
National TPA cuts FWA losses 31% with deployed unsupervised outlier model
A national TPA was carrying FWA losses ~3.2% of paid claims. Lumiknox built and deployed an unsupervised outlier-detection model combined with a supervised classifier trained on the TPA’s historical SIU outcomes. After 9 months in production, identified FWA cases rose 2.4x and net losses fell 31%.
-31%FWA Losses
2.4xCases Identified
9moTo Steady State