HealthEdge Risk Adjustment and HealthEdge Quality
Elevate Risk Score Accuracy and Quality Performance
Accurate. Compliant. Audit-Ready. Across Every Line of Business.
Health plans face growing challenges in improving performance and outcomes. Manual processes drive up costs, delay care, and complicate compliance. It’s time for a smarter solution.
- Documentation Risk: Nearly 30% of claims fail CMS validation due to insufficient documentation — even when diagnoses are accurate.
- Coding Accuracy: ICD-10 error rates in medical records range from 20% to 50%, exposing health plans to significant Risk Adjustment Data Validation (RADV) audit liability.
- Quality Performance: With roughly 64% of Medicare Advantage members enrolled in 4-Star plans or higher for 2026, falling short on quality performance has significant financial consequences.
Disconnected technologies and manual interventions limit the flexibility health plans need, slowing adaptation and hindering continuous improvement in addressing today’s utilization management demands.
98%+
Coding accuracy rate exceeding industry benchmarks
3:1
Average ROI on prospective provider engagement programs
77%+
Year-over-year hybrid measure rate improvement with Quality360®
Introducing Risk Adjustment and Quality
HealthEdge delivers a comprehensive, end-to-end solution for health plans seeking to improve risk score accuracy, drive quality measure performance, and ensure audit-ready documentation. By combining next-generation AI technology with a team of AHIMA and AAPC-certified coders, we create a "glass box" environment — transparent, traceable, and fully defensible.
Our HITRUST-certified platform spans the full risk adjustment and quality lifecycle, from retrospective coding to prospective provider engagement to HEDIS® measurement and Stars consulting — all integrated within the broader HealthEdge ecosystem.
Comprehensive Capabilities Across the Risk Adjustment & Quality Lifecycle
HealthEdge Risk Adjustment and HealthEdge Quality offer a suite of integrated capabilities designed to address every dimension of risk adjustment and quality improvement — deployable together as a complete solution or independently to meet your plan's specific needs.
HealthEdge Retrospective Risk Adjustment
Transform retrospective coding from a tactical requirement into a strategic competitive advantage. AI-augmented workflows, human-in-the-loop validation, and an always-on QA protocol deliver accurate, defensible gap closure at scale.
HealthEdge Prospective Risk Adjustment
Synchronize data at the point of care to drive risk score accuracy and close clinical gaps. Delivered via Electronic, Remote, and On-Site engagement models — meeting providers where they work while elevating HEDIS® performance.
Quality360® HEDIS® Engine
An NCQA-certified SaaS HEDIS® engine, abstraction, and data analytics platform delivering 95%+ retrieval rates, 77%+ YoY hybrid measure improvement, and zero audit issues on retrospective submissions.
RADV Audit Support
Comprehensive audit readiness backed by pre-emptive correction programs, OIG Toolkit logic embedded directly in our platform, and expert teams providing full RADV, HRADV, and OIG audit support.
Why HealthEdge Risk Adjustment and HealthEdge Quality?
What sets HealthEdge apart is the combination of proprietary technology, certified human expertise, and deep integration within the HealthEdge platform — delivering outcomes that standalone point solutions simply cannot match.
- Proprietary Context-Aware AI: Purpose-built for risk adjustment — not a generic model. Our engine uncovers hidden conditions and drives coding efficiency exceeding 50% over manual processes.
- Traceable Decision Framework: Every code is linked to clinical evidence and coder logic, creating a fully transparent, audit-ready architecture — a critical advantage over opaque legacy systems.
- Expert Human-in-the-Loop: AHIMA and AAPC-certified coders are dynamically allocated to complex charts and high-impact conditions where expertise delivers the greatest value.
- True EMR Interoperability: Integration with all major EMR systems delivers CDI alerts and HCC gap notifications directly within provider workflows — minimizing friction and maximizing adoption.
- Unified HealthEdge Ecosystem: Deep integration with GuidingCare® converges risk adjustment with care management, enabling health plans to harness the full promise of a connected data platform.
- Flexible Deployment: Available as a cloud-based SaaS platform or a full-service partnership — adaptable to your plan's operational model and growth trajectory.
Built for Every Line of Business
Full support across government-funded and commercial populations — so your risk adjustment and quality programs scale with your book of business and adapt to evolving regulatory requirements.
- Medicare Advantage: HCC coding, RAF optimization, RADV audit defense, and Stars performance improvement for MA plans of all sizes.
- Dual Eligibles: Coordinated risk and quality strategies purpose-built for the complexity of the dual-eligible population.
- Medicaid: Comprehensive Medicaid risk adjustment coding and HEDIS® quality programs align to state-specific requirements.
- ACA / Exchange: Accurate risk adjustment data submissions and quality measure support across commercial exchange populations.
Ready to Advance Your Risk Adjustment & Quality Strategy?
Partner with HealthEdge Risk Adjustment and HealthEdge Quality to deploy solutions that deliver innovation, ensure compliance, and drive tangible financial resilience across your health plan.
Additional Resources