Secure Cloud-based Clinical-AI Analytics Solutions For Managing Risk Adjustment program

Serving Payer, Providers, ACOs participating in risk-sharing arrangements

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360-DEGREE MEMBER DATA VIEW

VALIDATING SUBMISSIONS AGAINST YOUR CLAIMS AND EHR MEDICAL RECORDS

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PROVEN ENCOUNTER SUBMISSIONS ENGINE

FINANCIAL RECONCILIATION TO MINIMIZE RISK AND MAXIMIZE REVENUE

ADVANCED CLINICAL-AI PLATFORM

BUILD YOUR OWN CUSTOM-TRAINED LARGE LANGUAGE MODEL ON YOUR DATA

PREDICTIVE RISK ADJUSTMENT ENGINE

CLOSE PREDICTED GAPS AT POINT OF CARE THROUGH EHR-INTEGRATED PHYSICIAN WORKFLOW

3-Pillar Value Proposition

1. Chart AI Copilot 

Delivering real-time clinical intelligence at the chart level

Leverages proprietary NLP and LLMs to scan structured & unstructured data for HCCs and missed coding opportunities. 

  • Assists coders and QA teams with compliant code suggestions, source-linked references, and confidence scoring. 

  • Supports prospective, retrospective, and concurrent chart reviews. 

  • Tracks every action for audit-readiness and traceability (full audit trail). 

  • Seamlessly integrates with your existing EHR or coding platform. 

2. CMS Submission Compliance

Automated validation and reconciliation across your entire submission pipeline

Ingests and analyses X12 837 I/P/D encounter files. 

  • Monitors TA1, 999, 277CA, MAO-002, MAO-004, MMR, and MOR files for errors and rejection trends. 

  • Real-time dashboards flag rejected or dropped encounters. 

  • Built-in reconciliation tools link rejected claims to charts, ensuring no revenue is lost. 

  • Keeps your plan audit-ready and aligned with CMS requirements. 

3. RAF Optimization

Drive more accurate risk scoring and maximize revenue without over-coding

Identifies undocumented HCCs across clinical records using AI. 

  • Prioritizes high-impact, high-chronic patients to close the right gaps first. 

  • Supports prospective programs that improve performance before the look-back ends. 

  • Reduces risk of over- or under-coding by flagging anomalies with contextual evidence. 

  • Generates predictive RAF impact and submission completeness metrics.

Learn About latest CMS Medicare Advantage Rules

Exploring CMS’s 2026 Advance Notice: Key Updates for Medicare Advantage and Part D Programs

Summary

  • The 2026 Advance Notice for Medicare Advantage and Part D Payment Policies proposes significant updates, including a 5.93% effective growth rate for Medicare Advantage capitation rates, the highest in nine years. It also fully implements the 2024 CMS-HCC risk adjustment model and completes phase-in adjustments for indirect medical education costs. For the Part D program, a $2,100 annual out-of-pocket cap on prescription drug costs is introduced, along with new manufacturer discounts in the initial and catastrophic coverage phases. Additionally, there are updates to risk adjustment to align with the new benefit design and out-of-pocket cap.

  • Star Ratings enhancements include the introduction of a new Kidney Health Evaluation measure for patients with diabetes and increased weights for metrics on improving or maintaining physical and mental health. The PACE program will gradually transition to the updated CMS-HCC model by 2029, starting with a 10% blend in 2026. The MARx system will migrate to a cloud-based infrastructure, and normalization factors will be updated to incorporate trends from pre- and post-COVID-19 periods. These changes aim to improve payment accuracy, beneficiary protections, and quality outcomes.

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