BELLEVUE, Wash.--()--Edifecs, Inc., a global health information technology solutions company, today announced Point of Care Suspects, expanding its comprehensive Risk Adjustment offering to surface suspects at the point of care. The solution improves financial performance and operational efficiencies by streamlining delivery of potentially undocumented conditions to clinicians. This results in significantly improved risk adjustment code capture while strengthening collaboration between providers and payers.

"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, 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."

Incorporating mature industry-leading clinical AI, natural language processing (NLP), and machine learning capabilities, Edifecs’ Risk Adjustment offering analyzes both structured and unstructured data to produce a comprehensive view of each member’s known and suspected conditions, providing actionable insights across the risk adjustment lifecycle – prospective, concurrent, and retrospective. The new Point of Care Suspects capability surfaces these insights within existing clinical workflows, allowing providers to address care and coding gaps in real time without disrupting care delivery. By leveraging decades of technological and healthcare expertise, Edifecs ensures confidence in every code.

A large provider-sponsored health plan and Edifecs customer shared that "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." In fact, by incorporating unstructured data in suspecting, Integrated Delivery Networks (IDNs) capture 30% more HCCs, on average, than they do using structured data alone according to customer feedback.

Edifecs Point of Care Suspects supports both payers and providers:

  • Providers are incentivized to accurately identify and document member conditions. Today, this requires a lot of manual effort and still yields incomplete results. By deploying the Edifecs solution, providers have a more comprehensive scope of potential suspects. Suspects delivered directly to the point of care are less labor-intensive than those managed outside the clinical workflow.
  • The solution creates better alignment between coding and documentation, lowers compliance risks, and eases the workload associated with audit defense. Additionally, it helps reduce provider frustration by streamlining systems and minimizing unnecessary tasks, leading to smoother operations and improved satisfaction.
  • Payers experience assurance that risk adjustment scores accurately reflect patient complexity, maximizing revenue while reducing discrepancies that could lead to audits, audit defense, or compliance penalties. Improved quality metrics enhance bonus incentives and market reputation, and strengthen provider collaboration. Identifying underreporting patterns helps guide targeted quality improvement efforts.

To learn more about Edifecs Point of Care Suspects, please visit: https://www.edifecs.com/solutions/risk-adjustment-clinical-suite.

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 with their healthcare operations cloud solutions and data management platform, which includes its market leading healthcare interoperability cloud solution. Edifecs healthcare SaaS solutions, available on public, private, and hybrid clouds, serve as the foundation that eliminates stakeholder friction to overcome healthcare’s biggest challenges, including accelerating value-based care adoption and obtaining more complete and accurate care funding. For more information, visit www.edifecs.com.