Risk Analytics - Powered by AI

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

Intelligence That Thinks Like a Reviewer
HealthDataMax’s platform is powered by Agentic AI — a coordinated network of analytical agents and fine-tuned Large Language Models (LLMs) trained on CMS, RADV, and clinical documentation logic. These intelligent agents continuously review claims, charts, and CMS submissions to ensure every diagnosis is supported, compliant, and financially accurate. They don’t just automate—they reason, reconcile, and recommend, delivering human-level accuracy at enterprise scale

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