AI Risk Adjustment Software for Medicare Advantage

Smarter Risk Adjustment Starts with Better Clinical Data

Medicare Advantage organizations depend on accurate risk adjustment to understand patient complexity, support appropriate reimbursement, and manage population health.

However, critical diagnoses are frequently buried in lengthy clinical notes, hospital discharge summaries, specialist reports, and other unstructured medical records. Manual chart reviews make identifying these conditions time-consuming and difficult to scale.

ForeSee Medical addresses these challenges with AI-powered healthcare risk adjustment software that analyzes both structured and unstructured patient information.

By identifying potentially undocumented chronic conditions and connecting findings to supporting clinical evidence, ForeSee ESP helps healthcare organizations improve coding accuracy while maintaining physician and coder oversight.

How ForeSee Medical's AI Risk Adjustment Software Works

1. AI-Powered Disease Identification

ForeSee ESP uses proprietary NLP and machine learning to analyze medical records and identify potential Hierarchical Condition Category (HCC) diagnoses.

The platform evaluates information from multiple clinical sources, including:

• Electronic health records (EHRs)
• Physician progress notes
• Hospital discharge summaries
• Specialist consultation reports
• Laboratory results and medications
• Claims and historical diagnosis information
• Health information exchange (HIE) documents

These insights help providers recognize chronic conditions that may otherwise be overlooked during routine patient encounters.

2. EHR-Integrated Clinical Decision Support

Traditional risk adjustment management often relies on retrospective coding reviews performed after the patient visit.

ForeSee ESP supports prospective and concurrent workflows by presenting relevant disease suspecting insights at the point of care.

Providers can review potential conditions, evaluate supporting documentation, and determine whether diagnoses should be addressed during the encounter.

This workflow helps reduce unnecessary chart searching while supporting more complete clinical documentation.

3. Evidence-Based HCC Coding

Accurate Medicare Advantage risk adjustment requires more than identifying possible diagnoses. Each reported condition must be supported by appropriate clinical documentation.

ForeSee Medical's InstaVu® technology connects AI-identified conditions to the original supporting medical record.

Users can quickly locate the relevant clinical evidence, helping coders and providers validate diagnoses before they are finalized.

4. Documentation Compliance and Audit Readiness

Medicare Advantage organizations face increasing scrutiny over HCC coding accuracy, documentation integrity, and Risk Adjustment Data Validation (RADV) audits.

ForeSee ESP's Compliance Module helps identify potential documentation deficiencies and diagnoses that may require additional clinical support.

By making supporting evidence easier to locate and review, the platform helps organizations strengthen documentation defensibility and prepare for compliance reviews.

5. CMS-HCC V28 Optimization

The CMS-HCC V28 risk adjustment model places greater emphasis on diagnosis specificity and accurate representation of patient disease burden.

ForeSee Medical's V24-to-V28 Optimizer® helps organizations identify relevant coding changes and evaluate appropriate diagnosis alternatives under the updated risk adjustment model.

This functionality supports more accurate risk scoring and helps coding teams adapt to evolving Medicare Advantage requirements.

Improve Patient Risk Stratification with AI-Powered Insights

Effective patient risk stratification requires a complete understanding of each patient's chronic conditions, clinical complexity, and historical medical information.

Traditional risk scoring software often depends heavily on claims data and structured EHR fields, which may not capture the full clinical picture.

ForeSee ESP expands the available information by analyzing unstructured clinical documentation and identifying potentially relevant diagnoses.

These insights can help organizations:

• Identify patients with complex chronic conditions
• Recognize potentially underdocumented disease burden
• Improve the completeness of HCC diagnosis capture
• Support more accurate risk score calculations
• Prioritize patients who may require additional clinical review
• Improve visibility into population-level disease complexity

By combining AI-driven disease identification with clinical validation, ForeSee Medical helps organizations develop a more complete picture of patient risk.

Risk Adjustment Analytics That Support Better Decisions

Risk adjustment analytics should provide more than retrospective reporting. Healthcare organizations need actionable insights that help improve clinical documentation, coding productivity, and operational performance.

ForeSee ESP supports risk adjustment analytics through reporting capabilities that help organizations monitor diagnosis identification and coding workflows.

Available reporting capabilities include:

• HCC disease reporting
• Productivity reporting by user
• Detailed coding activity reports
• Unreconciled diagnosis reporting by provider
• Exportable data for operational analysis

These capabilities help risk adjustment leaders identify workflow bottlenecks, monitor documentation review activities, and improve visibility across coding teams.

Traditional Risk Adjustment vs. ForeSee ESP

Many healthcare organizations still depend on labor-intensive chart reviews and disconnected coding workflows. ForeSee ESP introduces AI-assisted automation and clinical evidence verification to simplify these processes.

Benefits for Medicare Advantage Plans and Provider Organizations

Improve HCC Coding Accuracy

AI-assisted disease identification helps coding teams recognize potentially missed conditions while supporting clinical verification and appropriate documentation.

Increase Chart Review Productivity

ForeSee ESP automates time-consuming medical record analysis and helps users locate relevant documentation without manually searching through lengthy patient charts.

Support More Accurate RAF Scores

More complete identification and documentation of qualifying chronic conditions can help organizations better represent patient disease burden in risk adjustment calculations.

Strengthen Medicare Advantage Compliance

Evidence traceability and documentation review tools help organizations identify potential coding deficiencies and support more defensible HCC submissions.

Reduce Administrative Burden

By bringing AI-powered clinical insights into existing workflows, ForeSee ESP helps providers and coding teams spend less time searching through medical records.

Scale Risk Adjustment Operations

AI-assisted chart review and centralized reporting help organizations manage larger patient populations without relying exclusively on manual review processes.

Built for Medicare Advantage Risk Adjustment Teams

Medicare Advantage Health Plans

Support coding accuracy, documentation integrity, and risk adjustment oversight across provider networks.

Healthcare Provider Organizations

Equip physicians with actionable clinical insights at the point of care while reducing manual documentation review.

Accountable Care Organizations (ACOs)

Improve visibility into patient disease burden and support risk adjustment workflows across participating practices.

Management Services Organizations (MSOs)

Standardize risk adjustment management processes across multiple practices and provider groups.

HCC Coders and CDI Teams

Accelerate clinical evidence verification, identify documentation gaps, and improve coding productivity.

Why Choose ForeSee Medical for Risk Adjustment Software?

ForeSee Medical combines AI-powered clinical analysis with human judgment to help healthcare organizations improve Medicare Advantage risk adjustment workflows.

• Advanced clinical AI: Proprietary NLP and machine learning analyze complex medical records for potential chronic conditions.
• Point-of-care integration: Relevant clinical insights are presented within provider workflows.
• InstaVu® evidence verification: Direct access to original supporting clinical documentation.
• Compliance-focused workflows: Tools to identify potential documentation deficiencies and support audit preparation.
• CMS-HCC V28 optimization: Support for evolving Medicare Advantage risk adjustment models.
• Human validation: Physicians and coders retain responsibility for reviewing and confirming diagnoses.

Frequently Asked Questions About AI Risk Adjustment Software