Brochure: Retrospective Coding - The Next Generation of Risk Adjustment

In an environment of intensifying regulatory scrutiny, HealthEdge delivers a retrospective coding solution that transforms this tactical requirement into a strategic competitive advantage. We move beyond simple gap closure by fusing proprietary, next-generation AI with deep human expertise. This creates a transparent, "glass box" environment that provides accurate and fully defensible results for your health plan.

While legacy operations depend on manual processes or "black box" automation, HealthEdge utilizes a traceable technology framework. Our solution validates the clinical truth within your data, ensuring your plan is fortified against RADV, HRADV, and OIG audits while maximizing financial performance.

The HealthEdge Advantage: Precision at Scale

Nearly one-third of claims fail CMS validation due to incomplete documentation, even with accurate diagnoses. HealthEdge addresses this challenge by shifting from standard chart reviews to a comprehensive, technology-driven data intelligence strategy. We ensure your charts are complete, compliant, and CMS-ready from inception.

Our Core Differentiators

• Proprietary Context-Aware AI: Unlike generic AI models, our engine is purpose-built for risk adjustment. It uncovers hidden conditions and clinical insights with granular precision, driving 50% greater coding efficiency.

• Human-in-the-Loop Validation: We believe in augmenting human expertise, not replacing it. As your plan scales, our system dynamically assigns our experienced, certified AHIMA and AAPC coders to complex charts. By using AI to triage routine documentation, expert coders focus on nuanced clinical scenarios where their skills deliver the greatest compliance and financial impact.

• Traceable Decision Framework: Every code captured is linked directly to clinical evidence and specific coder logic. This creates an audit-ready architecture that provides total transparency—a critical advantage over the opaque methods of legacy systems. This level of oversight is key to revitalizing a health plan, as demonstrated in A Health Plan's Success Story.

• Dynamic Intelligence Dashboards: Transition from reactive to proactive management. Our real-time analytics provide live, actionable insights into provider trends, coding productivity, and emerging compliance risks, allowing you to pivot strategy mid-cycle.

Verified Performance by the Numbers

HealthEdge delivers proven results across accuracy, scale, and expertise.

A Unified, Tech-Forward Workflow

We streamline healthcare operations with a seamless, end-to-end ecosystem designed for the modern digital health payer. Our process, from gap identification to chart submission, is built for scalability and precision, helping health plans manage growth and balance sustainability.

1. Predictive Gap Identification:
   Our platform leverages machine learning and advanced claims logic to uncover unreported or suspected HCC conditions from historical data. It can ingest your existing chase lists or generate them algorithmically to create a unified, high-yield workflow.

2. AI-Augmented Review: 
   Our web-based coding interface automatically highlights priority clinical data. This allows our certified coders to focus on complex decision-making rather than manual data hunting, ensuring EDPS submissions are both complete and compliant.

3. Defensible Quality Assurance: 
   Our "Always-On" QA protocol uses automated over-reads to instantly flag Adds and Deletes. With continuous internal reviews and two annual third-party audits, our accuracy creates a fortress around your revenue.

4. Actionable Outcomes: 
   Gain real-time visibility into performance. Our analytics suite empowers you to identify provider-level documentation deficiencies as they occur, enabling targeted education and improved prospective performance.

Elevate Your Risk Adjustment Standard

Stop settling for the status quo. Partner with HealthEdge to deploy a retrospective coding solution that delivers innovation, ensures compliance, and drives tangible financial resilience for your health plan.