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Change Healthcare, Health Fidelity Apply AI to Risk Adjustment

Change Healthcare and Health Fidelity are applying AI and natural language processing to the risk adjustment coding process.

AI, NLP, and risk adjustment coding

Source: Thinkstock

By Jennifer Bresnick

- Change Healthcare and Health Fidelity have announced a collaboration to offer AI-driven risk adjustment coding solutions for Medicare Advantage, ACA commercial, and Medicaid payers.

The tool leverages natural language processing (NLP) and machine learning to increase the accuracy of claims and help health plans meet their compliance obligations.

By transforming the risk adjustment process from a manual task into an automated process, health plans will be able to ensure that coding is accurate and complete, the companies said.

“Risk adjustment requires a high level of clinical data acquisition and careful analysis of millions of medical records to assign the proper diagnosis code to claims,” said Doug Duskin, senior vice president and general manager, Clinical Review, Change Healthcare.

“Health Fidelity’s NLP engine has demonstrated very high sensitivity in identifying ICD and HCC codes, enabling their clients to realize a 20-30 percent increase in risk capture. This added capability is exciting as we expect it will lead to better gap closure and improved quality of care and outcomes for members.”

The two companies will offer a single enterprise solution that combines analytics, chart retrieval, coding, and submission.  Artificial intelligence will help select high-risk charts for further review.

The use of natural language processing will ensure greater accuracy, which will translate into more exact reimbursement.

“The Natural Language Processing engine automatically scans and sorts member data to identify ICD and HCC codes for coding review, the companies explained in an accompanying fact sheet.

“Coders are presented a prioritized, organized queue of diagnostic codes for addition or deletion via machine learning, resulting in significantly greater accuracy, speed, and completeness of review.”

NLP will replace the need for certified coders to comb through charts without any automated prioritization, and may reduce variation in the results.

Change Healthcare and Health Fidelity expect that the tool will reduce the likelihood of a CMS audit while ensuring more correct reimbursement is paid more quickly.

“With their scale, established payer relationships, and years of coding experience, Change Healthcare is the ideal partner to extend the reach of our natural language processing within risk-adjustment coding,” said Steve Whitehurst, Health Fidelity CEO.

“The resulting combination of analytics, artificial intelligence, and services allows us to customize our solutions to meet customer goals and improve overall performance and outcomes.”


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