Risk Adjustment
Coding Suite

Retrospective review is a valuable part of ensuring care continuity and closing coding gaps. However, retrospective reviews occur months after care has been administered, and the resulting lag in payment adjustments and documentation accuracy can create challenges for payers and providers alike. In addition, only a handful of state Medicaid programs permit retrospective chart reviews and/or supplemental submissions, so without concurrent measures, it can be difficult to obtain an accurate picture of risk.

Provider abrasion is often the result of inefficient processes or excessive administrative requirements that complicate workflows and distract providers from their patients. The right technology should fit seamlessly into existing provider workflows, eliminate duplicative administrative work, and allow providers to focus on delivering the best care possible.

The timely claims payment rule requires health plans to pay 90% of all clean claims received from practitioners within 30 days of receipt, 99% of clean claims within 90 days of receipt, and all other claims within 12 months of the date of receipt.

AI and Natural Language Processing (NLP) can be used to process and analyze massive amounts of patient data—including free-text notes added to patient charts by clinicians—in a fraction of the time it would take to do manually, improving coding speed by over 300%, according to our internal analysis. This analysis can also be used to highlight any claims that do not include chronic conditions that were diagnosed prior to that visit or under- or over-coded claims for existing or new conditions, enabling payers to return claims to their provider partners for correction and resubmission.