Risk Adjustment

Chart Retrieval

Fast, Reliable, And Affordable Access To Clinical Data Through Electronic Chart Retrieval

Eliminate The Time, Cost, And Reliability Issues Of Manual Chart Retrieval.

Automatic Manual and Electronic Retrieval Workflow

Enables automation of chase lists, campaigns, and worklist creation while auto assigning and rebalancing workloads based on chart priority, campaign progress, and corresponding deadlines

Provides the ability to track campaigns, charts, teams, and vendor performance via a dashboard, calendar, and alert features

Facilitates an easy, direct upload for providers, alongside the ability to manage roles and permissions for various users

Centralized Record Storage

Reduce chart retrieval costs and connect data directly to coding solutions

Expand data access with a central data repository can be utilized by multiple departments to eliminate waste

Experience valuable insight on where the data is being used, why, and how to further optimize operations.

EHR Agnostic Solution

Minimize resources required and disruption to providers to retrieve records from EHRs

Amplify coding productivity boosts from Retrospective and Post-Encounter coding solutions with same-day retrievals

Improve data quality by eliminating obscured information with seamless, electronically transmitted files.

Risk Adjustment Clinical Suite

Leverage AI To Refocus Risk Adjustment Around The Patient, Enhancing Care And Improving Value-Based Payment Accuracy

Value-Based Care Has Two Core Objectives: Reduced Cost And Improved Risk Adjustment. With Edifecs, Augment EHR-Workflows With AI-Derived Insights That Surface Risk And Condition Gaps For Evaluation Before Claims Are Submitted. Our Approach Optimizes RAF Capture At Every Clinical Touchpoint, Offering Tools That Unburden Providers, Surface Overlooked Gaps, And Help Organizations Of All Sizes And Risk-Maturity Scale. Improve Revenue Integrity, Compliance, And Patient Care To Thrive Under Value-Based Care With The Edifecs Risk Adjustment Clinical Suite. Experience The Benefit Of Over 25 Years Of Health Information Technology Leadership And Industry Leading NLP Technology That Ensures Plan, Provider, Coder, And Patient Satisfaction.

Best-in-Class NLP Engine

Understands the complexities of clinical language -- including grammar, syntax, context, and intent

Applies proprietary algorithms and logic to identify a set of patients or features that align to the model’s purpose, like uncovering patients with diagnosis gaps or documentation that lacks specificity, at cascading degrees of confidence

Provides the greatest depth and breadth of industry standard terminology support, including SNOMED, ICD-10, RxNorm, and LOINC

Creates a universal clinical source of truth via a comprehensive patient profile that unites structured data elements to the newfound clinical information

Point-of-Care

Uncover up to 35% verified codes over retrospective passes for more effective care plans inclusive of all comorbidities

Impact all risk adjustable populations at the point –of care, freeing physicians from excess administrative time through documentation support within the EHR

Generate patient and provider insights that drive performance, population health, condition targeting, patient outreach, and more

AI-powered, risk focused chart preparation support that refocuses risk adjustment around the patient, changing a traditionally actuarial processes to a real, clinical utility

Post-Encounter Review

Perform in-depth, NLP supported reviews of codes prior to submission, enabling Medicaid and ACA RAF capture in all 50 states

Shorten A/R cycles and forecasting from years to months with increased confidence due to faster and more accurate payment turnaround

Shift any coding burdens off providers and back into the hands of coding experts

Pre-Visit Planning

Go beyond claims-based reconfirmation and add net-new conditions identified from unstructured data

Submit with confidence knowing each new condition is clinically validated during encounter processing

Improve care and reduce emergent visit costs with NLP supported chart preparation and patient targeting

Net fuller, more accurate value-based care payments by ensuring that risk scores, an assessment of disease burden and a deciding factor in funding, are routinely evaluated.

Risk Adjustment Coding Suite

End Multi-Vendor Management Headaches: AI-Enabled Coding Automation With Compliance And Submission Tools, All Through Edifecs.

Value-Based Care Has Two Core Objectives: Reduced Cost And Improved Risk Adjustment. With Edifecs, Unify Your Risk Adjustment Operations. Our Approach, From Coding To Submissions, Helps Organizations Of All Sizes Create A Risk-Maturity Scale, Improve Revenue Integrity And Compliance, And Not Just Shift To Value-Based Care, But Thrive Under It. The Edifecs Risk Adjustment Coding Suite Delivers An Automated, SaaS-Based Tech Platform Encompassing Retrospective And Pre-Submission Coding, Compliance And Audit Support, And Submissions. Experience The Benefit Of Over 25 Years Of Health Information Technology Leadership And Industry Leading NLP Technology Ensuring Plan, Provider, Coder, And Member Satisfaction.

Audit Safeguards

Redaction logic identifies codes that lack sufficient evidence and automatically flags them to ensure compliant and accurate submissions that protect against future audits

QA functionality allows for “third pass” code reviews, customizable queues, and code intensity, condition, and population targeting

Chart linking ensures that submitted codes are attached to the relevant clinical evidence.

Best-in-Class NLP Engine

Understands the complexities of clinical language -- including grammar, syntax, context, and intent

Applies proprietary algorithms and logic to identify a set of patients or features that align to the model’s purpose, like uncovering areas to add, remove, or modify HCC codes at cascading degrees of confidence

Provides the greatest depth and breadth of industry standard terminology support, including SNOMED, ICD-10, RxNorm, and LOINC

Creates a universal clinical source of truth through a comprehensive patient profile that unites structured data elements to the newfound clinical information.

Retrospective Review

Our technology combines natural language processing (NLP) and analytics to extract valuable insights into healthcare datafrom unstructured data in medical charts, allowing for performance improvements across the board:

5X increase in coder productivity

20-30% increase in risk capture

40% decrease in costs

All member charts that contain no coding errors are eliminated from the queue, ensuring coding time is focused only where needed, eliminating wasted efforts.

Risk Analytics

Identify risk-centric care gaps and find missed RAF opportunity with ACA, MA, Medicaid, and other value-based care populations

Enjoy granular operational insights on providers, coders, members, and more to drive internal expertise with performance management

Identify areas for additional risk adjustment education and training to further optimize outcomes.

Submissions

This Solution Helps End Multi-Vendor Management Headaches, Leverages AI-Enabled Coding Automation With Integrated Submission Compliance And Analytics Tools, Breaks Down Encounter Operations Silos, And Ensures Compliance And Risk Adjustment Accuracy Across All Managed Care Lines Of Business.

Managed Care Plans Of All Types Struggle With Managing The Accuracy Of Risk-Adjusted Revenue Data And With Conforming To Submission-Related Encounter Guidelines. These Issues Are Compounded By Constantly Changing Regulations, State-Specific Nuances And The Use Of Multiple Submission Systems. Overcoming These Challenges Requires A Best-In-Class Encounter Submission Platform Backed By NLP-Enabled Operations And Analytics. Edifecs Delivers The Industry’s Most Complete Suite Of Risk Adjustment Solutions, By Powering Managed Care Plans' Success Across Lines Of Business.

Decrease State Penalties

Utilize dashboards to report and track SLA performance

Enable mass correction capabilities to fix errors and resubmit data

Leverage Edifecs-managed module updates based on State-specific changes

Improve Risk-Adjusted Revenue Accuracy

Enable prospective risk adjustment analytics for direct Provider support in clinical settings

Leverage HCC-prioritized exception workflows, backed by AI/ML technology

Implement flexible business rules to improve first pass rates

Reduce Audit Exposure

Deploy a comprehensive solution to streamline MAO-002 and MAO-004 reconciliation

Reduce the submission of unlinked chart reviews

Enable up-front data validation to prevent the introduction of poor-quality data

Streamline Regulatory Compliance

Enable continuous compliance-monitoring based on changes to the HHS-Developed Risk Adjustment Model Algorithm

Best-in-class regulatory change management.

NLP Suspecting

Not All NLP (Natural Language Processing) Engines Are Created Equally; Excellent Risk Adjustment Performance Requires A Purpose-Built NLP.

Healthcare Data Is Waiting. Almost 80% Of A Patient’s Information Is Locked Inside Unstructured Data. But It Doesn’t Have To Be That Way. Edifecs’ NLP Engine Creates A Deeper, More Holistic View Into Healthcare Data Around Patient Populations. Getting These Critical Insights Into A Community’s Health Status Offers Numerous Benefits, Including The Keys To Improving A Patient’s Health. Our Suspect Analytics Allow Organizations To Capture The Full Picture Of Patient Risk From All Available Documentation, With Convenient Delivery Alternatives And Customizable Settings To Ensure The Quality, Control, And Probability Required To Engage Clinicians.

Best-in-Class NLP Engine

Don’t settle for off the shelf products. Edifecs NLP has processed over 3.1 billion pages of clinical documentation

Experience the impact of transitioning from working off 20-30% of available data to >90%

See clinically focused, machine learning-driven development with expert oversight at work. Edifecs NLP technology is on a trajectory of continuous, industry leading performance

Experience what Edifecs NLP can do for you. It understands the complexities of clinical language -- including grammar, syntax, context, and intent

Convert unstructured data - like physician notes entered in an EHR - into a structured extraction of clinically meaningful intelligence that can be systematically processed by machine to derive predictive insights.

Configurable Delivery

Suspected conditions can be delivered directly into Edifecs’ SaaS-based software applications during Pre-Visit Planning or at the Point-of-Care

Alternatively, suspects can be routed through flat-file output, form-based output (CCV), or through EPIC BPA

Regardless of delivery, the associated evidence and rationale for the suspect is presented for clinical validation.

Customizable Output

All outputs are checked against available claims data and linked to available evidence. In prospective use-cases, if a suspect already appears on a claim, it is considered confirmed and not delivered to the user

Global best practices, CMS policy-related changes, and customizable business rules can override logic templates, delivering only organizational-specific preferences depending on current and long-term goals

Each condition or code surfaced has an associated confidence score based on the confluence of available evidence and the rate at which similar outputs are accepted or rejected, both globally and locally.