Risk Adjustment Solution Edifecs

Risk Adjustment
Post-Visit Review

Retrospective reviews play a valuable role in effective risk adjustment operations, but retrospective reviews often occur months after an encounter has taken place, if not longer. The more time that passes, the greater your odds of missing risk-adjustable opportunities due to gaps in documentation. These gaps impact reimbursement and compliance, and they make it more difficult for provider organizations to deliver on population health initiatives.

Edifecs Post-Visit Review leverages AI and NLP to analyze all available clinical data and quickly reconcile it with Hierarchal Condition Category (HCC) codes on the claim. With our SaaS-based solution, administrative teams can add HCCs with supporting clinical documentation, or remove codes for patient conditions that are resolved or lack the clinical data to substantiate them.

Enable Program Compliance

Edifecs helps organizations maximize care funding through complete and accurate coding.

Risk Adjustment Solution 1
  • Enable support staff to review more encounters
  • Reduce workloads for more efficient use of resources
  • Spend less time chasing down documentation to support diagnoses

Increase upstream activities

Reduce organizational dependence on retrospective reviews.

HCC Risk Adjustment 2
  • Prioritize encounters based on risk/opportunity
  • Measure the likelihood of care gaps with AI-enabled confidence scoring
  • Suggested coding changes are highlighted prior to submission

Leverage AI-powered insights activities

Identify supported diagnoses with AI analysis of structured and unstructured chart data.

Risk Adjustment in Healthcare 3
  • Shift the burden of coding from clinicians back to support staff
  • Comply with coding guidelines via standardized risk capture
  • Track performance and monitor trends for added/deleted codes

Strengthen risk adjustment processes

Manage all your risk-based contracts through one uniform workflow.

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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Risk Adjustment for Providers Guide
Complete and accurate risk capture is essential to success in value-based contract performance. This guide examines the four points of opportunity where provider organizations can identify and address gaps to achieve greater financial results, ensure regulatory compliance, and enhance care quality.
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Natural Language Processing in Healthcare: The Clinical and Financial Opportunity of Suspecting
In part 2 of this two-part eBook series, we examine what suspecting is, the types of suspecting maturity, review clinical suspect examples, and cover best practices for provider suspect deployment before and during a patient encounter.
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