Edifecs Expands Risk Adjustment Capabilities with Point of Care Suspects Solution
Edifecs, Inc., a global leader in health information technology solutions, has announced the launch of Point of Care Suspects, a new enhancement to its comprehensive Risk Adjustment offering. This innovation is designed to surface potential undocumented conditions at the point of care, optimizing financial performance and operational efficiency for healthcare providers and payers. By streamlining the identification and delivery of suspected conditions directly within existing clinical workflows, Point of Care Suspects significantly enhances risk adjustment coding accuracy, ultimately leading to improved collaboration between healthcare providers and insurers.
Addressing the Challenges of Risk Adjustment Coding
The complexity of risk adjustment coding poses significant challenges for healthcare organizations, often leading to incomplete documentation, revenue inaccuracies, and increased administrative burdens. Edifecs aims to transform this process with its cutting-edge clinical AI, which integrates seamlessly into provider workflows, ensuring that undocumented conditions are accurately captured and addressed in real time.
“Healthcare organizations face mounting challenges from risk adjustment coding complexity, impacting both patient care and revenue accuracy. Point of Care Suspects builds on our market-proven, best-in-class clinical AI to transform this process,” said Dr. Summerpal Kahlon, Chief Medical Officer at Edifecs. “By seamlessly integrating with existing workflows, we’re improving the provider-payer relationship while reducing provider burnout and compliance risk—exactly the kind of win-win healthcare needs.”
Leveraging Advanced AI and Data Insights
Point of Care Suspects leverages industry-leading artificial intelligence (AI), natural language processing (NLP), and machine learning (ML) to analyze both structured and unstructured healthcare data. This enables the system to generate a comprehensive profile of each patient’s known and suspected conditions, offering actionable insights at multiple points throughout the risk adjustment lifecycle—prospective, concurrent, and retrospective.
Key Features of Point of Care Suspects:
- AI-Driven Suspecting: The platform identifies potential undocumented conditions using sophisticated algorithms and presents them to providers within their workflow.
- Seamless Workflow Integration: Insights are embedded directly into existing electronic health records (EHR) and clinical systems, reducing administrative burden.
- Real-Time Decision Support: Providers can act on suspected conditions immediately, improving both care quality and financial outcomes.
- Compliance and Audit Readiness: Enhanced alignment between coding and documentation reduces compliance risks and simplifies audit defense.
Real-World Impact and Customer Success
The introduction of Point of Care Suspects has already demonstrated measurable benefits for healthcare organizations. A large provider-sponsored health plan using Edifecs’ solution shared: “The more complete and relevant we can be in surfacing both recapture and net new conditions for clinician review, the better the overall patient care and provider experience. Minimizing irrelevant or inaccurate conditions improves the quality of hierarchical condition category (HCC) capture with less provider abrasion.”
One key advantage of the solution is its ability to leverage unstructured data—such as clinical notes, physician dictations, and lab results—alongside structured data, leading to more accurate condition identification. Integrated Delivery Networks (IDNs) utilizing unstructured data in suspecting capture 30% more HCCs, on average, compared to those relying solely on structured data.
Benefits for Providers and Payers
Providers:
- Increased Accuracy and Efficiency: Enables clinicians to identify and document conditions with greater precision, reducing manual effort and administrative workload.
- Enhanced Compliance: Aligns coding with clinical documentation, minimizing compliance risks and improving audit outcomes.
- Reduced Provider Burden: By streamlining data presentation and removing unnecessary administrative tasks, the solution helps reduce physician burnout and improves job satisfaction.
Payers:
- Improved Risk Adjustment Accuracy: Ensures that risk scores reflect actual patient complexity, leading to optimized reimbursement and reduced financial discrepancies.
- Better Provider Collaboration: Strengthens relationships between payers and providers by fostering transparency and streamlined workflows.
- Higher Quality Metrics: Enhances performance on quality measures, improving eligibility for bonus incentives and boosting market reputation.
Future Outlook and Industry Implications
As the healthcare industry continues to evolve, AI-powered risk adjustment solutions like Edifecs’ Point of Care Suspects are poised to play a pivotal role in advancing value-based care initiatives. The ability to surface actionable insights at the point of care represents a paradigm shift in risk adjustment, transforming how providers and payers collaborate to ensure accurate coding and optimal patient outcomes.
Learn More
For additional information on Edifecs Point of Care Suspects and how it enhances risk adjustment capabilities, please visit: https://www.edifecs.com/solutions/risk-adjustment-clinical-suite.
