ProspectIQ™ | Prospective Suspecting

Turn Data Into Actionable Provider Insights

ProspectIQ™ is Health Data Max’s next-generation prospective suspecting solution, powered by AI and clinical intelligence. It combines historical claims, labs, pharmacy data, and medical charts to generate high-confidence suspect lists, enabling health plans to proactively engage providers and capture actionable feedback—driving better risk adjustment outcomes.

Why Prospective Suspecting Matters

Healthcare data is growing exponentially. Plans often struggle to identify underreported conditions and prioritize provider outreach efficiently. ProspectIQ™ leverages AI for:

  • Detecting potential gaps in risk adjustment coding before submission

  • Highlighting high-value patients for provider review

  • Automating workflows for outreach and feedback capture

  • Reducing manual chart review effort and provider fatigue

With ProspectIQ™, your plan can act before the submission deadline, ensuring accurate documentation and improved revenue capture.

How It Works

ProspectIQ™ integrates multiple data sources and applies predictive analytics to generate actionable suspect lists. The platform follows a seamless workflow:

  1. Data Aggregation – Collects historical claims, lab results, pharmacy data, and medical chart notes.

  2. Signal Engine – Identifies potential HCC gaps and prioritizes suspects based on confidence scores.

  3. Outreach Orchestrator – Automates provider outreach with context-rich information for easier action.

  4. Provider Inbox – Captures provider feedback directly in the system, keeping the loop closed.

  5. Continuous Learning – Feedback retrains the model for higher accuracy over time.

Key Features

ProspectIQ™ is designed for usability and efficiency, featuring:

  • Evidence-First Suspects: Transparent reason codes, MEAT/TAMPER prompts, and risk indicators for every suspect.

  • Workflow Automation: Prioritize outreach and track provider responses with minimal manual intervention.

  • Closed-Loop Feedback: Provider feedback directly improves suspect accuracy and reduces “chase fatigue.”

  • Customizable Rules: Tailor scoring models for CMS-HCC, RxHCC, CDPS, or plan-specific risk models.

  • Intuitive Dashboard: Visualize suspect lists, outreach status, feedback rates, and actionable KPIs.

Modules

  1. Signal Engine
    Aggregates multi-source data to detect potential gaps in diagnosis coding. Generates confidence scores for each suspect.

  2. Outreach Orchestrator
    Manages automated outreach campaigns to providers, including reminders, attachments, and context-rich messages.

  3. Provider Inbox
    A dedicated interface for providers to review suspects, submit feedback, and upload supporting documentation.

  4. ROI & Compliance Tracker
    Monitor risk-adjusted revenue impact, track HCC validation, and ensure compliance with CMS regulations.

Benefits at a Glance

Benefit Impact
Early Gap Identification Capture missing HCCs before submission deadlines
Efficient Provider Engagement Reduce outreach time and effort by 40%+
Improved Risk Scores Accurate coding increases risk-adjusted revenue
Closed-Loop Learning Feedback continuously improves suspect accuracy
Compliance Confidence Transparent audit-ready documentation

Why Health Data Max?

ProspectIQ™ leverages the proven Health Data Max platform:

  • Seamless Integrations: Works with EHRs, claims systems, and third-party data sources.

  • Data-Driven Insights: Uses advanced analytics to prioritize high-value patients and providers.

  • Scalable for Your Plan: Designed for MA, ACO, and other value-based care programs.

  • Expert Support: Implementation and onboarding guided by Health Data Max’s risk adjustment experts.

How Plans Use ProspectIQ™

  • Medicare Advantage Plans: Identify underreported HCCs and improve risk-adjusted revenue.

  • ACO / Value-Based Programs: Focus outreach on high-risk, high-impact patients.

  • Provider Networks: Facilitate documentation capture at point-of-care with minimal workflow disruption.

Key Metrics You’ll See

  • Number of potential HCC suspects identified

  • Provider engagement and response rates

  • Percentage of confirmed HCCs captured before submission

  • Revenue impact from closed-loop suspect validation

  • Reduction in manual chart reviews

Get Started with ProspectIQ™

Step into the future of prospective suspecting. Health Data Max makes it easy to implement ProspectIQ™ with minimal disruption:

  • Pilot Program: Test with a subset of patients or providers.

  • Full Rollout: Scale outreach across your plan with automated workflows.

  • Continuous Optimization: Models learn from provider feedback to improve accuracy over time.

ProspectIQ™ – Turn Historical Data into Actionable Provider Insights and Drive Better Risk Adjustment Outcomes.

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