Reimagining Risk Adjustment in a Changing Regulatory Era

As Medicare Advantage (MA) plans grapple with new rules, stronger audit scrutiny, and the recent shift from version 24 to version 28 of the CMS-HCC model, Health Data Max presents its Risk Adjustment Platform—secure, AI-enhanced, and designed for today’s compliance, coding, and financial realities. Our solution fits payers, Accountable Care Organizations, and risk-bearing providers who need more than legacy workflows. We combine prospective, concurrent, and retrospective risk adjustment paths with the agility to adapt to shifting coding maps, updated diagnostic categories, and evolving audit expectations.

Built for Accuracy. Designed for Action.

Anchored in proprietary natural language processing (NLP) and custom-trained LLMs, our platform now also incorporates the latest mid-year CMS updates, V28 diagnostics re-mappings, and stricter enforcement around unsupported HCC codes. We extract diagnoses, condition relationships, and supporting clinical evidence from both structured claims and unstructured provider narratives. The system flags both missing risk-capturing opportunities and potential audit exposures, giving actionable insight before claims are submitted.

What Sets Our Risk Adjustment Platform Apart

• Next-Gen Prospective HCC Discovery
  Using updated V28 mappings, our AI models identify members whose conditions qualify under the new HCC definitions (e.g. severe persistent asthma, more granular chronic disease categories) but whose documentation hasn’t caught up.

• Robust Retrospective Chart Validation & Audit Defense
  Link or delink diagnoses based on documentation strength. Support for RADV (Risk Adjustment Data Validation) audits, especially with recent enforcement focus on unsupported diagnosis coding.

• Smart Chart Prioritization Engine
  Rank charts by potential financial impact, audit risk, condition severity, and coding changes under V28. Zero in on high-value open charts first.

• Real-Time Coding & Decision Support
  Alerts in workflow: if a diagnosis is no longer HCC-eligible under V28 or needs additional documentation; suggest correct codes; ensure coding aligns with current CMS policy and recent updates like phase-in percentages.

All-in-One Platform. No Gaps Left Uncovered.

With a modern interface and modular design, our platform supports every stakeholder—from clinicians & coders to compliance and audit teams. Role-based dashboards, intuitive configuration, and plug-ins for EHR / claims systems allow your organization to focus on performance—not managing siloed tools.

If your goals include:

• Staying ahead of RADV audits

• Maximizing RAF (Risk Adjustment Factor) under V28 and beyond

• Capturing high-impact chronic and acute conditions

• Minimizing coding leakage, unsupported diagnoses, and documentation shortfalls

…then HealthDataMax gives you the tools, visibility, and automation to act with confidence and compliance.

DATA CONSOLIDATION & ETL

Data Consolidation & ETL

Ingest structured + unstructured encounter data, map to latest ICD-10 / CMS-HCC v28 sets, prepare for clean submission.

Claims Transactions Processing

STREAMLINED CLAIM TRANSACTIONS

Supported for all X12 837 types (Institutional, Professional, DME) with HCC-aware validations.

CMS Responses & Rejection Handling

DETAILED AND ACTIONABLE

Decode TA1, 999, 277CA, MA-002, MA-004, MORs etc.; automatically relink or flag charts for follow-up.

Error Management & Correction Workflow

RESOLUTION & CORRECTION

Configurable queues, built-in remediation steps, documentation trails.

Advanced HCC Analytics

MACHINE LEARNING DRIVEN ANALYTICS

ML-driven rule engine for recapture under V28, predictive modeling of RAF, trend tracking under phase-in period.

Full Encounter Support

FULL-RANGE OF SUPPORT TOOLS

Supports standard, capitated, void/adjusted, chart-linked & unlinked, deleted, and atypical providers; adapts to emerging CMS policy changes.