HF360 Compliance identifies diagnoses that were previously submitted to and confirmed by CMS/HHS but for which there isn’t sufficient clinical evidence within medical records to substantiate the diagnoses. The incorrectly submitted diagnoses are identified using NLP and analytics for accurate and targeted intervention. The solution includes a streamlined workflow that allows risk adjusters and internal auditors to conduct targeted “two-way” reviews with unprecedented speed and accuracy.
“As risk adjustment organizations are constantly being asked to do more with less, ensuring utmost compliance across all information sources – providers, vendors, coders – becomes more and more difficult,” said Health Fidelity CEO Steve Whitehurst, “We wanted to leverage our technology to deliver a solution that makes this efficient and nearly effortless.”
The solution can be used by risk adjustment professionals (coders, managers, quality assurance staff, internal auditors) to streamline the validation of diagnoses previously submitted on claims or prior supplemental submissions. Upon review of each flagged condition, the reviewer can validate that the condition is sufficiently substantiated, or initiate a delete of the condition to be submitted if it truly lacks the documentation necessary.
Key benefits delivered by HF360 Compliance include:
- Obtain audit-ready results – ensure that all submitted codes have substantiating documentation as part of the member record for optimal compliance and audit preparedness
- Increase efficiency – identify specific areas with compliance risks for a much more targeted and streamlined claims data validation
- Identify gaps in provider education – analytics help to identify systemic areas of coding and documentation gaps across the provider network and provide actionable feedback to facilitate continuous improvement
“Given that 80-90% of risk adjusted codes get submitted directly via claims from providers, only focusing on compliance of your coders is an incomplete strategy,” said Whitehurst. “With HF360 Compliance, organizations can now deploy a much more holistic compliance strategy that creates a sustainable, continuous improvement process.”
HF360 Compliance is available for purchase as an additional option in Health Fidelity’s HF360 Retrospective Review solution, or as a standalone compliance solution.
To learn more about HF360 Compliance, visit us online.
Health Fidelity is a registered trademark of Health Fidelity, Inc.
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SOURCE Health Fidelity
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