Risk Analytics - Powered by AI

HealthDataMax (HDM) delivers a next-generation, AI-enabled platform for continuous HCC / risk adjustment insights — so you see risk as it evolves, not just quarterly.

See Risk as It Happens — Not Quarterly

CMS recalculates risk scores only three times a year, leaving plans blind to RAF drift and potential revenue leakage.

HDM’s HCC Risk Analytics continuously tracks:

  • Member-level RAF scores

  • Payment accuracy

  • Documentation completeness

Know your risk today, not months from now.

Why It Matters

  • Stay ahead of CMS updates: Act before gaps impact revenue.

  • Protect revenue: Identify missed HCCs and underpayments in real time.

  • Reduce audit risk: RADV-ready dashboards and evidence-linked HCCs.

  • Support providers: Point-of-care guidance and actionable insights.

How HCC Risk Analytics Works

1. Real-Time RAF & Payment Tracking

  • Live recalculation of member and cohort RAF scores.

  • Instant alerts for payment variances and coding gaps.

  • Compare internal scores with CMS snapshots to prevent surprises.

2. Retrospective & Prospective Analysis

  • Retrospective: Find missed HCCs from past encounters and prioritize by revenue impact.

  • Prospective: Predict chronic conditions for early intervention.

  • Concurrent: Real-time prompts improve documentation at the point of care.

3. Submission Accuracy & Compliance

  • Automated checks ensure complete and compliant submissions.

  • Reduce rejected encounters and RAF leakage.

  • Maintain a full audit trail for every HCC suggestion.

4. RADV Audit Readiness

  • Track verified, pending, and rejected HCCs in a simple dashboard.

  • Historical trends and predictive scoring help plan audit risk mitigation.

Key Features at a Glance

  • Real-Time RAF Engine: Daily recalculations of risk and payments

  • Payment Variance Alerts: Immediate notification of revenue gaps

  • V28-Aware Modeling: Fully compliant with CMS-HCC V28

  • Evidence-Based Suspecting: Every HCC suggestion linked to chart evidence

  • Provider Engagement Tools: Targeted dashboards for high-impact patients

  • Predictive RAF & Forecasting: Multi-scenario projections for year-end planning

  • Submission Monitoring: Track accepted vs. rejected encounters

  • Audit-Ready Documentation: Complete evidence trails for RADV

Interactive Dashboards

  • RAF Drift Tracker: Daily RAF score updates for members and cohorts

  • Opportunity Pipeline: Visualize open coding gaps and chronic recapture

  • Documentation Completeness: ICD-10 specificity and evidence coverage

  • Payment Forecast Monitor: Early detection of payment variances

  • Provider Action Center: Flag high-priority charts and interventions

Expanded Benefits & Use Cases

1. Protect Revenue

  • Catch underpayments before CMS updates.

  • Identify missed HCCs with AI-driven evidence review.

2. Improve Compliance

  • Maintain complete submission audit trails.

  • Ensure coding and documentation align with CMS standards.

3. Optimize Provider Workflows

  • Real-time prompts for HCC capture.

  • Highlight patients with the highest risk and opportunity.

  • Reduce administrative burden with targeted, actionable insights.

4. Predictive Insights

  • Forecast year-end RAF scores and revenue.

  • Simulate impact of coding and documentation improvements.

  • Plan resources and provider outreach proactively.

Why HDM?

  • Continuous insight: Track risk, revenue, and documentation every day.

  • Predictive analytics: Simulate outcomes under multiple scenarios.

  • Provider-friendly: Simple dashboards, actionable alerts, and workflow guidance.

  • Audit-ready: RADV compliance with evidence-backed trails.

  • Secure & compliant: HIPAA and HITRUST-ready cloud infrastructure.

From reactive to proactive: HDM turns HCC analytics into a continuous advantage.

Business Impact

Metric Before HDM With HDM
RAF Updates 3× per year (CMS) Real-time recalculations
Revenue Leakage Detection Reactive Continuous monitoring
Audit Preparedness Manual review Automated anomaly flags
Submission Accuracy 80–85% 95%+ submission completeness
Payment Forecasting Lagging Predictive and live
Provider Engagement End-of-year Year-round
Chronic Condition Recapture Partial 25–35% improvement

Compliance & Governance

  • Fully aligned with CMS-HCC V28 and RADV guidelines

  • Supports human-in-the-loop coding review with evidence justification

  • End-to-end encryption for all PHI data (in transit and at rest)

  • Continuous audit logging for all risk score changes and payment calculations

  • Integrates directly with EHR, claims, and CMS submission workflows

Integration & Technology

  • Data Sources: Claims, encounters, labs, pharmacy, eligibility, provider notes

  • Outputs: RAF projections, payment alerts, dashboards, API connectors

  • Deployment: Secure cloud, modular integration, or on-premise

  • Access Control: Role-based dashboards for different user teams

  • Interoperable: Works seamlessly with EHRs, payer platforms, and submission gateways

Results Our Clients See

  • 25–35% improvement in chronic condition recapture

  • 20% reduction in submission rejection rates

  • 40% faster detection of payment variances

  • Consistent year-round provider engagement

  • Clear audit trails supporting RADV readiness

Ready to See It in Action?

Discover how HDM’s HCC Risk Analytics helps you manage risk and revenue continuously — not quarterly.

Request a Demo