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HCC Coding Validation for Health Plans

Concurrent & Retrospective Solutions: MEAT-Criteria Driven, RADV-Ready

Accurate risk adjustment coding is critical as CMS RADV audits intensify. Our HCC Validator safeguards health plans with concurrent validation for real-time MEAT compliance and retrospective review for audit defense. By aligning every diagnosis with MEAT criteria and flagging high-risk codes early, we help protect revenue, strengthen documentation, and ensure compliance readiness.

Why It Matters

In today’s value-based environment, accurate risk adjustment coding is critical. CMS RADV audits are increasing in frequency and intensity, and the margin for error is shrinking.

  • Financial Risk: Even small error rates can lead to significant paybacks.
  • Compliance Risk: Non-MEAT compliant diagnoses expose plans to audit failure.
  • Operational Risk: Poor documentation can impact RAF scores, STAR ratings, and provider network trust.

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Our Solution: The Inferscience HCC Validator

Dual Approach: Concurrent + Retrospective HCC Coding Validation

Concurrent Validation

  • Real-time MEAT compliance check during provider documentation
  • Instant provider feedback to correct or add supporting documentation
  • Prevents inaccurate or unsupported codes from entering the claim stream
  • Improves first-pass coding accuracy and RAF integrity

 

Retrospective Validation

  • Post-encounter review of submitted diagnosis codes
  • Identifies MEAT deficiencies and coding errors
  • Identifies OIG high target codes and potential audit risk
  • Flags documentation gaps for provider education
  • Creates defensible audit trail for RADV preparedness
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MEAT Criteria Alignment

Every validated code is assessed for:

RADV Audit Defense Built In

✅ Maintain a compliance-ready coding library

✅ Automated audit packages with source documentation linking

✅ Identify high-risk codes before they trigger CMS recoupment

✅ Demonstrate proactive oversight to regulators and partners

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Key Benefits to Providers & Health Plans

Reduce RADV recoupment risk: Save millions in potential paybacks

Increase coding accuracy: Higher RAF scores & risk revenue

Improve provider performance: Ongoing documentation education

“In 8 months, our organization has presented more than 269K HCC codes to Providers and Advance Providers. Our coders and 300+ primary care providers find it to be very straightforward and user friendly.”

athenaOne User
Billing Staff, Multispecialty

“Inferscience really speeds up the HCC process. It’s a great tool for providers as well as coding personnel in catching opportunities throughout the entire chart.”

athenaOne User
Administrative Staff, Multispecialty

“It has been a great opportunity to work with the Inferscience program, it is very user friendly. It enhances our accuracy and consistency with the HCC coding and allows us to produce quality service for our providers.”

athenaOne User
Administrative/Clerical Staff, Multispecialty

AI Solution for Healthcare Payers

Our healthcare API empowers payers and third-party vendors to harness advanced HCC coding analysis, facilitating healthcare interoperability and delivering deeper insights to address the evolving needs of patients, providers, and payers.

Integrate with Ease

Payers or third-party vendors connect the API to their existing system. 

Upload Data 

Claims files are uploaded (PDF or CCDA documents), after which the data is extracted and analyzed using intelligent rules.

Retrieve Analysis 

The API delivers analysis in JSON format that can be retrieved in seconds. 

Stay ahead of CMS audits. Protect your revenue. Elevate your compliance.

Let’s talk about how our HCC Validation Platform can safeguard your plan.

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