More effective and accurate risk capture
Easily identify high-risk patients and close documentation gaps for better clinical and financial outcomes.
Identify. Prioritize. Perform.
Complete and accurate risk capture is essential to success in value-based contracts. Effective risk adjustment can improve revenue accuracy, enhance care quality, and reduce compliance and audit risks—but achieving this is often easier said than done. Combing through mountains of clinical data requires time and resources that many provider organizations simply don’t have at their disposal.
The Risk Adjustment Clinical Suite is a SaaS-based, modular solution that seamlessly integrates with EHRs to augment—not undermine—existing clinical workflows. Using AI-derived insights and our proprietary Natural Language Processing (NLP) engine, the Clinical Suite enables provider organizations to simultaneously achieve complete and accurate risk capture for multiple patient populations.
Clinical Suite Products
Pre-Visit Prep
Point-of-Care Advisor
Post-Visit Review
Retrospective Review
Risk Adjustment Clinical Suite: The Key To Value-Based Success
By delivering better satisfaction, better clinical outcomes, and better population health, value-based care can transform healthcare. Effective risk adjustment is essential to success in value-based care—but for many provider organizations, achieving complete and accurate risk capture is easier said than done.
Effective risk adjustment is key to succeeding in value-based care, but many provider organizations are struggling to achieve complete and accurate risk capture. Providers need to be able to uncover and correct risk gaps at every stage of care delivery, not just after claims are submitted.
The Risk Adjustment Clinical Suite from Edifecs leverages AI & NLP to help provider organizations close care gaps, flag risk-adjustable opportunities, and reconcile clinical data with HCC codes—without disrupting clinical workflows.
It’s time to work smarter, not harder.
We help streamline risk adjustment workflows for more accurate and effective risk capture.
Frequently Asked Questions
01
How much is a properly coded Hierarchical Condition Category (HCC) code worth?
The specific value of a single HCC code varies according to the rate set by CMS and the risk scoring methodology in use (e.g., CDPS, CDPS+Rx, or D-SNP, depending on the state); however, gaps in HCC coding can cause up to a 12% loss in annual revenue for healthcare providers.
02
How are RAF scores calculated?
Numerical weight is assigned to a patient’s demographic factors (age, sex, race, ZIP code, residence, disability status, socioeconomic status, Medicaid eligibility, and institutional status) and to the HCC codes in their chart; the values of the HCC codes are measured cumulatively.
These numbers are added together to calculate the Risk Adjustment Factor (RAF) score. The RAF score is then multiplied by the CMS rate for each individual HCC to calculate the expected annual cost of care.
03
What is the most common reason for improper payment?
According to a 2022 HHS report, insufficient documentation was responsible for an astonishing 91.7% of improper payments by CMS:
| Reason for Improper Payment | Frequency |
|---|---|
| Insufficient, inadequate, or missing documentation | 81.2% |
| Incorrect coding | 10.5% |
| Other | 8.3% |
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