Risk Adjustment Software for Health Plans
Medicare Advantage health plans face growing pressure to improve risk adjustment accuracy, maintain documentation compliance, and prepare for expanding CMS audits. With CMS-HCC V28 fully implemented and increased RADV scrutiny, health plans need greater visibility into diagnoses submitted across their provider networks.
ForeSee Medical's ESP® platform uses artificial intelligence (AI), Natural Language Processing (NLP), and machine learning to identify missed HCC conditions, validate clinical documentation, reduce coding errors, and strengthen compliance across Medicare Advantage populations.
Improve HCC Coding Accuracy and Risk Adjustment Performance
Incomplete coding can prevent Medicare Advantage health plans from accurately representing their members' health complexity. Important chronic conditions are often overlooked when clinical information is scattered across EHRs, specialist reports, hospital records, and other sources. ForeSee ESP® analyzes structured and unstructured clinical data to identify potentially missed HCC diagnoses and improve coding accuracy.
ForeSee helps Medicare Advantage plans:
Identify Missed HCCs: Detect chronic conditions overlooked in claims and coding data.
Analyze Clinical Records: Review EHR data, physician notes, specialist reports, and PDFs.
Optimize CMS-HCC V28 Coding: Identify diagnoses relevant to the current risk adjustment model.
Improve Annual Recapture: Flag previously documented conditions requiring current-year evaluation.
Reduce Coding Errors: Provide supporting clinical evidence for coding validation.
ForeSee helps health plans improve risk adjustment accuracy while reducing time-consuming manual chart reviews.
Strengthen Documentation Integrity and Coding Compliance
For Medicare Advantage health plans, identifying additional diagnoses is only part of the challenge. Every submitted HCC must have appropriate clinical documentation supporting its validity. Unsupported diagnoses can create financial exposure, compliance concerns, and potential repayment obligations.
ForeSee's AI-powered Compliance Module helps health plans identify documentation deficiencies and potential coding issues across their provider networks.
The Compliance Module helps health plans:
Detect potentially incomplete or insufficient clinical documentation.
Flag unsupported diagnoses and coding discrepancies for review.
Verify evidence supporting previously reported conditions.
Provide documentation guidance to participating providers.
Improve coding compliance consistency across provider organizations.
ForeSee helps health plans capture clinically supported diagnoses while identifying potential overcoding risks, strengthening revenue integrity and documentation compliance.
Improve RADV Audit Readiness and Reduce Compliance Risk
As CMS expands Risk Adjustment Data Validation (RADV) audits, Medicare Advantage health plans must be prepared to validate diagnoses with appropriate clinical evidence. Reviewing thousands of medical records across multiple provider organizations can be expensive and time-consuming.
ForeSee simplifies documentation verification with its proprietary InstaVu® technology, providing one-click access to the original medical record supporting an identified diagnosis. InstaVu® directs reviewers to the relevant page, highlighting supporting clinical information.
InstaVu® helps health plans:
Quickly locate documentation supporting HCC diagnoses.
Reduce manual chart review and validation time.
Identify potentially unsupported coding submissions.
Improve consistency across internal compliance reviews.
Streamline RADV audit preparation.
Combined with ForeSee's Compliance Module, InstaVu® helps health plans strengthen documentation oversight and prepare more efficiently for CMS audits.
Improve Risk Adjustment Oversight Across Provider Networks
Medicare Advantage health plans depend on participating providers to accurately document and report member conditions. Differences in EHR systems, coding practices, and documentation workflows can create inconsistent risk adjustment performance. ForeSee helps standardize HCC identification, documentation verification, and compliance review across provider networks. Its AI-powered workflows improve coding efficiency, provide actionable insights to participating providers, and give risk adjustment teams better visibility into documentation gaps and unresolved issues. ForeSee also maintains HITRUST r2 Certification, reinforcing its commitment to healthcare information security.
Improve Coding Accuracy. Protect Revenue Integrity. Prepare for RADV.
Medicare Advantage health plans need more than traditional coding software. They need a solution that supports accurate diagnoses, defensible documentation, and efficient compliance oversight. ForeSee Medical helps health plans improve risk adjustment performance, reduce compliance exposure, and strengthen RADV readiness—all within one AI-powered platform.
