Buried in Outdated & Redundant Gap Data?

In today’s value-based care (VBC) environment, accurate coding is about more than reimbursement. It is essential for quality care, compliance, audit readiness, and long-term financial performance. Yet many medical groups are still overwhelmed by outdated and redundant data as they work to identify and address Hierarchical Condition Category (HCC) gaps.

This challenge is especially common for provider organizations working with MSOs, health plans, ACOs, and other value-based care partners. These organizations often receive large amounts of claims-based data intended to support risk adjustment. But claims data does not always reflect what is happening with the patient today. It may include previously addressed diagnoses, acute conditions that have resolved, or ICD-10 codes that no longer map the same way under CMS-HCC V28.

Providers and coding teams are then left to sort through this information, compare it with current clinical documentation, and determine which conditions are still relevant and supported.

Claims data can also lag behind actual care, making it difficult to identify current conditions and address documentation gaps at the point of care. At the same time, older coding workflows and EHR tools may continue to surface diagnoses based on previous risk models.

The result is more work for providers and greater compliance risk.

Outdated Workflows Create Unnecessary Burdens

Traditional risk adjustment workflows often require providers and administrative teams to log into multiple portals, review long lists of diagnoses, compare claims against current medical records, and manually determine what should or should not be documented.

This takes valuable time away from patient care. More importantly, simply presenting more diagnoses does not solve the problem. Providers need to know whether a condition is clinically relevant, supported by the medical record, and appropriately documented for the current encounter.

As CMS expands its focus on Medicare Advantage risk adjustment audits, documentation support has become increasingly important. Healthcare organizations need technology that can help identify potential HCC opportunities while also helping prevent unsupported diagnoses from being carried forward.

Manual, claims-driven workflows were not designed for this environment. Providers need timely clinical insights directly within their existing workflows.

A Smarter Approach With ForeSee ESP®

ForeSee ESP® by ForeSee Medical was designed to replace fragmented, manual risk adjustment processes with an intelligent platform that integrates with existing EHR workflows.

Rather than relying only on claims, ForeSee ESP® brings together information from clinical notes, claims, CMS reports, PDFs, HIEs, medications, labs, diagnostic reports, and other available clinical sources to create a more complete view of the patient.

Using proprietary natural language processing and disease-suspecting medical algorithms, ESP® analyzes structured and unstructured clinical information to identify potential chronic conditions and HCC coding opportunities.

Providers see these insights through easy-to-use disease cards, allowing them to quickly review relevant information and make their own clinical documentation decisions.

ForeSee’s InstaVu® feature makes the process even faster by giving users one-click access to the source documentation supporting a potential diagnosis. Instead of searching through an entire patient chart, providers and coders can quickly see the underlying clinical evidence.

Adding Compliance to Every Chart Note

Finding potential diagnoses is only part of modern risk adjustment. Healthcare organizations also need confidence that submitted diagnoses are supported by appropriate documentation.

ForeSee Medical’s Compliance Module adds another layer of protection by evaluating whether diagnoses meet Medicare documentation requirements.

The Compliance Module can identify documentation gaps, flag notes that may not meet requirements, and provide real-time guidance to help providers strengthen documentation before the encounter is complete.

This helps organizations move from a workflow focused primarily on finding more diagnoses to one focused on finding the right, clinically supported diagnoses.

For providers, that means clearer guidance at the point of care. For coders, it means less time searching through charts for supporting evidence. For compliance teams, it provides greater visibility into potential documentation issues before they become larger audit risks.

Less Chart Searching, More Actionable Information

ForeSee ESP® is designed to make risk adjustment easier for both providers and coding teams.

Instead of presenting long lists of claims-based suspects, the platform surfaces clinically relevant information with the evidence needed to evaluate it. Built-in clinical documentation improvement guidance helps providers document conditions more completely, while InstaVu® allows supporting information to be reviewed quickly.

Administrative dashboards also give organizations greater visibility across providers and patient populations, helping teams prioritize where attention is needed.

By bringing disease suspecting, clinical evidence, documentation guidance, and compliance into a single workflow, ForeSee helps reduce unnecessary chart review and administrative work.

Measurable Impact, Smarter Care

Healthcare organizations using ForeSee ESP® have reported meaningful improvements in efficiency, documentation, and risk adjustment workflows.

For providers, reducing the need to search through entire patient records can save significant time during annual wellness visits and other encounters. Coding teams can verify clinical evidence faster, while administrators gain a clearer view of documentation and compliance across their organization.

Most importantly, ForeSee helps organizations ensure that diagnoses submitted for risk adjustment accurately reflect the patient’s documented clinical condition.

That is becoming increasingly important as CMS expands RADV audits and increases scrutiny of unsupported Medicare Advantage diagnoses. Organizations need to identify legitimate conditions, but they also need processes that help prevent unsupported diagnoses from being submitted or recaptured.

Moving From More Coding to Better Coding

The future of risk adjustment is not simply about capturing more HCCs. It is about improving the accuracy, clinical support, and compliance of every diagnosis.

Relying on lagging claims data, disconnected portals, and outdated coding workflows makes that increasingly difficult.

ForeSee ESP® gives provider organizations a more current and clinically focused approach. By combining AI-powered disease discovery, one-click source documentation, real-time provider guidance, and Medicare documentation compliance, ForeSee helps teams identify supported conditions while reducing unnecessary administrative work.

The result is a smarter risk adjustment workflow built around what matters most today: accurate documentation, clinically supported coding, audit readiness, and better patient care.

Blog by: The ForeSee Medical Team