Edifecs’ new offering ensures accurate and efficient risk gap closure, reconciling targeted provider claims against historical member diagnoses in near real time before a claim is submitted

Edifecs Introduces Concurrent Risk Adjustment Solution

Janet Hohmann
415-240-6904
Janet.hohmann@edifecs.com

Edifecs, Inc., a global health information technology solutions company, today announced its new product, Concurrent Risk Adjustment (CRA). CRA helps Managed Care Organizations (MCOs) and payers serving other at-risk markets to intervene earlier in the risk adjustment process by sharing previously documented chronic conditions with providers. With CRA, organizations can drive more complete and accurate documentation and coding prior to claim submission and support better health outcomes for their members.

Edifecs’ SaaS-based offering was designed to meet the challenges MCOs and payers face when operating in states where retrospective reviews and supplemental submissions for Medicaid are prohibited or would incur financial penalties. Due to a limited ability to review claims for clinical accuracy and infrequent touch points with their members, MCOs in these states often struggle to intervene early in patient care, close risk gaps, and ensure chronic conditions are fully and accurately captured. Edifecs CRA helps address these challenges by:

• Identifying open risk adjustment gaps in near real time – CRA self-audits claims prior to adjudication ensuring all previously known conditions are captured in the claim
• Unifying disparate data sources – According to the American Journal of Managed Care (AJMC), only 50% of Medicaid beneficiaries see their Primary Care Physician (PCP) annually offering few opportunities for MCOs to reconfirm chronic conditions. CRA consolidates insights from across the medical community for a complete picture of each patient’s disease burden and then surfaces those conditions closer to the encounter using existing workflows. The result - better understanding of patients and populations and better outcomes
• Minimizing provider abrasion and administrative burden – With a library of customizable rules and intelligence integrated into existing workflows, CRA helps reduce administrative time, improve onboarding, and support provider education

“Unlike traditional retrospective methods, CRA allows payers to intervene earlier, ensuring that chronic conditions are accurately captured before claims are submitted. The benefits are twofold - improving care and reducing administrative waste by ensuring the claim is submitted correctly the first time,” said Chris Lance, chief product officer for Edifecs. “For states that do allow retrospective reviews or supplemental submissions, the process remains arduous and leads to significant delays in payments or reimbursements. CRA tackles the challenge of alleviating this administrative waste head-on.”

The SaaS-based nature of CRA allows Edifecs to independently configure each customer deployment to align with the unique needs of that customer. The product is generally available and being used across 27 states. Provider networks are empowered to re-submit claims unchanged if their clinical documentation does not support coding edits. CRA supports greater collaboration between payers and providers whose shared objective is ensuring that HCC coding reflects the true disease burden of the attributed population.

“Our Concurrent Risk Adjustment offering is a game-changer for the healthcare industry. The ability to close up to eight times more gaps over baseline is unparalleled, making CRA an indispensable intervention mechanism for any payer or Managed Care Organization,” continued Lance.

Edifecs CRA has already been purchased by some of the largest national health plans to improve care for millions of lives. Edifecs’ acquisition of Talix and Health Fidelity in 2022 allowed the company to expand its risk adjustment business, advance AI-based innovation, and integrate EHR capabilities.

To learn more about Edifecs CRA, please visit: https://www.edifecs.com/products/concurrent-risk-adjustment#product-details.

About Edifecs

Edifecs provides market leading technology to its payer and health system customers, which serve nearly 300 million people in the U.S. healthcare market. For over 25 years, Edifecs has enabled customers to unlock greater value by aggregating, normalizing, and unifying data with its Best in KLAS healthcare cloud interoperability platform. The Edifecs healthcare cloud is the foundation for the solutions that eliminate stakeholder friction to overcome healthcare’s biggest challenges, including accelerating value-based payment adoption and obtaining more complete and accurate care funding for alternative payment models. Edifecs’ solutions incorporate natural language processing, machine learning, and artificial intelligence to provide deeper insights into patients, populations, and business processes. As new standards and regulations continually emerge from government agencies, Edifecs is a proven partner to ensure its customers maintain “evergreen” compliance. Edifecs customers include 24 of the 25 top commercial health plans in the country, 29 of the 52 Medicaid programs, and 6 out of 10 of the largest health systems.

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