Unify your risk adjustment operations
Maximize your resources to find more risk-adjustable opportunities faster and ensure ongoing compliance.
Understand. Adapt. Simplify.
Value-based programs take a variety of forms, but they all have one thing in common: their success depends on effective and efficient risk adjustment. Health plans need to maximize revenues, identify risk-adjustable opportunities, and minimize coding errors, all while remaining compliant with changing regulatory guidelines.
With the Risk Adjustment Coding Suite, your organization can achieve each of these objectives—and you can do it at scale with a single, unified solution. Our AI-powered, SaaS-based suite is designed to cover all areas of your risk adjustment operations, from retrospective and pre-submission coding to compliance, submissions, and even audit support.
Coding Suite Products
Concurrent Risk Adjustment
Retrospective Review
NLP Suspecting
Edifecs’ Cloud-native, SaaS-based Risk Adjustment Coding Suite
Ensuring complete and accurate payments is the key to succeeding in value-based care.
Edifecs’ Risk Adjustment Coding Suite helps make a big job more manageable.
Risk adjustment is a big job, and health plans have to do it right if they want to succeed in value-based care. That means taking advantage of every opportunity to maximize revenues and ensuring complete and accurate payments. But it’s hard to do that when coding teams are struggling to keep up with the mountains of clinical data coming their way. The AI-powered Risk Adjustment Coding Suite from Edifecs helps health plans find and close diagnosis gaps, identify more suspected conditions, and cut down on coding errors. With the Coding Suite, health plans can spend less time on administrative tasks—and more time working to achieve their operational, compliance, and financial goals.
End multi-vendor management headaches and unify your risk adjustment operations with Edifecs.
Frequently Asked Questions
01
What is the benefit of concurrent risk adjustment relative to retro reviews?
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.
02
How can technology help with provider abrasion?
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.
03
What is the timely claims payment rule?
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.
04
How can AI support retrospective reviews?
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.
News & Insights
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.
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.
Improving Financial Performance Infographic
If your health plan revenue could use a lift, this two-prong approach—accelerating the transition to value-based care (VBC) and ensuring complete and accurate payments—are proven paths to net additional income.