New software identifies, corrects providers’ compliance risks

Health Fidelity, a risk adjustment vendor funded by the University of Pittsburgh Medical Center, has developed software that more accurately assesses risk adjustment results and reduce audit risk.

The software, called HF360 Compliance, uses natural language processing technology and statistical inference engines, mixed with analytics to identify and correct compliance risks. An inference engine uses artificial intelligence to apply rules to a specific knowledge base to arrive at a conclusion.

Use of the software is targeted at risk adjustment professionals such as coders, managers, quality assurance staff and internal auditors.

Also See: How to use IT effectively in risk-adjusting compliance

“Given that 80 percent to 90 percent of risk adjusted codes get submitted directly via claims from providers, only focusing on compliance of your coders is an incomplete strategy,” says Steve Whitehouse, CEO at Health Fidelity.



For instance, the software identifies diagnoses that were previously submitted to and confirmed by CMS but for which there isn’t sufficient clinical evidence within medical records to substantiate the diagnoses. Incorrect diagnoses then can be identified for review by risk adjusters or internal auditors. The end result is to streamline validation of diagnoses previously submitted on claims or prior supplemental submissions.

The HF360 Compliance software further can identify gaps in provider education, such as coding and documentation gaps and offer feedback to facilitate continuous improvement, according to the vendor.