4 benefits of an AI Audit Solution for Healthcare

In a recent audit finding shared by the Office of Inspector General (OIG), a Medicare Advantage (MA) healthcare organization ended up receiving at least $54.3 million in net overpayments. Most of the Hierarchical condition category (HCC) diagnosis codes submitted by the health plan was supported in the medical records, however, around 164 HCCs were not validated and resulting in overpayments. The health plan was then recommended to refund the overpayments to the Federal Government.¹

Every year, MA organizations lose hundreds and thousands of dollars due to inappropriate HCC coding, which in turn leads to regulatory penalties.

A proven, automated system can be used in order to optimize risk scores and income while reducing the burden on payers and medical coders.

Access to HCC summary reports for medical record data validation

NLP-Powered audit technology will automatically read patient’s charts and suggests:

  • Substantiated HCCs (codes that you should keep)
  • Unsubstantiated HCCs (codes that you should remove)
  • Unreported HCCs (codes that you should add).
  • Risk adjustment companies

This way you can easily identify the properly coded conditions, up-coded (over-claimed conditions), and under-coded (unclaimed conditions) to ensure the best practices of a chart review and audit.

Risk adjustment vendors

Improve HCC coding efficiency

AI-based Audit Solution offers a consolidated view of all member’s or patient’s records in real-time. In addition, an auto code suggestion is helping health plans, providers, medical coding companies, and MA chart auditing companies to perform a chart review & audit in less than 3 clicks.


My name is Kevin Barnes. I have a keen interest in content writing

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