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Smarter Risk Adjustment, Powered by Next-Gen AI

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HealthEdge delivers a new era of risk adjustment accuracy and efficiency through automation-first capabilities that drive audit-ready results. By integrating advanced artificial intelligence with a team of experienced leadership and expert coders, we serve as a direct extension of your health plan. Our secure, HITRUST-certified ecosystem provides compliant, cost-effective solutions with a measurable return on investment.

We empower health plans to improve care outcomes and business agility by combining strategic foresight, industry-leading talent, and rigorous attention to data integrity, provider collaboration, and regulatory adherence. Our solutions are designed to address the significant challenge of claims validation, where nearly 30% of claims fail CMS validation due to insufficient documentation.

Intelligent Coding and Validation Solutions

Harness the power of HealthEdge’s next-generation coding technology to achieve unmatched accuracy and significant cost savings. Our platform leads the market with advanced AI-driven insights that uncover every critical data point, optimizing for precision and reducing operational costs.

AI-Driven Coding Platform for Superior Accuracy

Our AI-powered platform is engineered to get it right the first time, minimizing manual interventions and accelerating processing times. Key features include:

  • Comprehensive Coverage: Fully supports Medicare Advantage, Duals, Medicaid, and ACA lines of business.
  • Transparent Scalability: Adaptable HCC logic and real-time analytics dashboards provide complete visibility into your operations.
  • Built-In Quality Assurance: An integrated, automated system ensures compliance while lowering the total cost of ownership.
  • Expert Human-in-the-Loop: While AI drives speed, our team of AHIMA and AAPC-certified coders validates accuracy and completeness for complex cases.

Automated Over-Reads for Precision RAF

Mitigate compliance risks with the industry’s most efficient validation solution. Our all-in-one Quality Assurance system leverages proprietary algorithms to proactively flag potential Adds and Deletes before submission to CMS.

  • Algorithmic Precision: AI instantly identifies discrepancies, streamlining workflows.
  • Expert Validation: Pre-highlighted changes are verified by expert coders to enhance Risk Adjustment Factor (RAF) accuracy.

AI-Driven SaaS Engine: The Core of Efficiency

Our proprietary AI engine is the bedrock of our precision, achieving over 50% efficiency gains in analysis. It transforms unstructured data into actionable intelligence, streamlining retrospective coding reviews and optimizing workflows. This solution is available as a cloud-based SaaS model or as a full-service partnership tailored to your plan’s needs.

Comprehensive Risk Adjustment Lifecycle Management

HealthEdge manages the entire risk adjustment lifecycle, from point-of-care provider engagement to final data submission, ensuring data integrity and audit-ready confidence at every stage.

Prospective Provider Engagement

Empower your provider network with advanced, EMR-integrated compliance tools. Our platform deploys real-time HCC and HEDIS® gap alerts directly within the provider workflow, ensuring clinical and documentation opportunities are closed during patient encounters.

  • Actionable Alerts: Data-driven targeting for prospective initiatives closes critical clinical gaps.
  • Tailored Education: Enhance documentation accuracy with provider-specific training tools.
  • Integrated Ecosystem: Our platform, including solutions like GuidingCare®, unifies data across risk adjustment and quality programs, such as our Quality360™ integrated HEDIS® engine.

Submissions Management and End-to-End Risk Mitigation

We ensure accurate, timely data submissions to CMS and provide comprehensive RADV audit support backed by scalable platforms and expert teams.

Feature

Description

Benefit

Data Integrity

Manages the entire submissions lifecycle, from supplemental claims linking to the add/delete process.

Ensures strict adherence to CMS requirements and maintains compliance.

Pre-Emptive Correction

Custom internal audit programs identify and fix vulnerabilities before they trigger a CMS intervention.

Reduces audit risk and enhances documentation quality proactively.

Coding Integrity

Utilizes OIG Toolkit logic within the platform to mitigate over-coding and establish RADV safeguards.

Drives more accurate reimbursements and strengthens compliance posture.

By identifying root causes of documentation deficiencies, we unlock strategic opportunities to optimize member care and ensure your program is prepared for any level of regulatory scrutiny.