Risk Adjustment Solution Edifecs

Risk Adjustment
Retrospective Review

Health plans need to maximize revenues, identify risk-adjustable opportunities, and minimize coding errors, all while remaining compliant with changing regulatory guidelines. Edifecs Retrospective Review combines claims information with structured and unstructured clinical data to build a full and comprehensive picture of your member population’s disease burden.

A 4X Increase in Coder Productivity

Edifecs helps health plans optimize their coder efficiency. Get in touch to learn more.

Risk Adjustment Solution 1
grow
  • Focus coder review efforts on highest-value opportunities
  • Effectively scale to accommodate larger volumes of data
  • Enable real-time tracking of coder productivity and accuracy

Increase coder productivity

Improve workflow efficiency to help your team handle more reviews.

HCC Risk Adjustment 2
reveal
  • Uncover ~1 additional HCC for every 4 MA or 5 ACA members reviewed
  • Reduce audit risk with two-way review that highlights adds and deletes
  • Improve revenue integrity and ensure accurate reimbursement

Ensure correct documentation

Leverage NLP to highlight and correct coding and documentation discrepancies.

Risk Adjustment in Healthcare 3
target
  • Identify records coded outside of standard guidelines (e.g., M.E.A.T.)
  • Isolate and prioritize coding gaps with NLP technology
  • Easily locate incremental diagnosis codes or HCCs

Improve RAF scores

Gain confidence in coding and documentation accuracy.

News & Insights

Risk Adjustment Overview Data Sheet
A comprehensive risk adjustment strategy: Scalable solutions and services designed to ensure revenue integrity and CMS/State compliance for managed care plans.
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WEDI Webinar: 3 Risk Adjustment Moves to Make Now
As the OIG continues to audit coding practices and in-home assessment validity, now is the time to ensure your risk adjustment operation isn’t exposing your organization to regulatory risk and penalties. In this webinar, hear the strategic adjustments industry experts recommend implementing now so you can be confident in your ability to sustain value-based care reimbursements compliantly and accurately as CMS continues to refine practices.
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Retrospective Review for Payers Data Sheet
Learn how AI and Natural Language Processing (NLP) can build efficiency for either internal or contracted coding teams, and in the process generate more revenue, compliantly.
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