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Revenue Integrity

Ensure revenue integrity for health plans participating in government and commercial programs while reducing risk exposure.

Solution Spotlight

  • Encounter Management

    Accurate, complete and timely encounter submissions are vital to accurate risk-adjusted payments and regulatory compliance in government and commercial programs. Learn how to proactively navigate these challenges and streamline program complexity.

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  • Risk Adjustment

    Edifecs Risk Adjustment drives powerful, precise, real-time risk score analytics at both the population and member level. Enables effective interventions while closing coding and care gaps. Integrated with Edifecs Encounter Management for comprehensive risk-adjusted program management

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Capabilities

Edifecs Revenue Integrity provides a flexible solution that enables health plans to mitigate revenue leakage, improve encounter submission accuracy and reduce both operational risks and costs.

Enhances risk analytics and forecasting

Drives accurate, timely and actionable risk adjustment analytics and revenue forecasting. Integrate these capabilities across government and commercial markets.

  • Identifies lower risk adjustment scores due to missing diagnosis codes
  • Improves A/R, financial summary and member economic insight
  • Provides prospective and retrospective HCC suspecting capabilities
  • Generates local risk scores based on most current view of accepted encounters

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Centralizes encounter management operations

Delivers a consolidated encounter book of record to track and monitor encounters across markets and programs (including Edge Server submissions).

  • Reduces encounter creation complexity and costs
  • Improves encounter first-pass rates
  • Enhances provider coding accuracy
  • Streamlines health plan entrance to new managed Medicaid markets via Knowledge Packs

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Adapts to changing market characteristics

Drives system flexibility to fluidly adapt to changing encounter submission formats and risk adjustment models across government and commercial markets.

  • Decreases IT costs and reliance
  • Enhances quality metrics management
  • Ensures adherence to compliance deadlines
  • Improves business continuity in the face of ongoing change

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