The winning formula: 7 benefits of AI-powered prospective risk

1. Risk prediction with precision‍

AI enables health plans to gain a complete view of patient risk by analyzing both structured and unstructured patient data and delivering up to 99% accuracy in HCC discovery.¹

By surfacing high-probability conditions—conditions that might otherwise go undocumented—health plans can improve the accuracy of their RAF scores by up to 33%.¹

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‍2. New levels of productivity‍

AI-driven automation enables health plans to accelerate data integration, eliminate manual chart reviews, and reduce administrative burden.

In what previously took a year, one large regional health plan was able to code 1.2 million charts in 4 months using AI-powered technology, resulting in 3x its coding speed².

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3. Smarter, simpler workflows

Health plan coding teams achieve a 30% increase in efficiency using AI-powered technology that scans the full scope of data for clinical evidence of diagnoses. ³

Coders can spend less time on paperwork and data entry and focus their efforts on validating whether the evidence surfaced by AI supports the diagnosis suggestion.

4. Stronger provider relationships

3 in 4 physicians think AI will improve their diagnostic ability, and seamless AI-powered integrations are making that a reality.⁴

Sophisticated integrations that can connect AI-powered technology with both health plan systems and provider EHRs facilitate new levels of collaboration with providers.

With HCC insights pushed directly into provider workflows – and minimal clicks required to access those insights – AI-powered technology transforms the patient encounter for more informed, efficient decision-making.

‍5. Cost efficiency to do more with less

AI empowers risk adjustment teams to do more with less, coding medical records in far less time and allowing more time to focus on closing care gaps year-round.

With AI-powered technology, health plans can lower overall administrative costs by 25%, allowing them to produce a greater value and achieve higher Star Ratings.⁵

6. Healthier patients, stronger outcomes

AI-driven prospective risk enables proactive care and enhances care coordination by surfacing previously undetected HCCs when they matter most – at the point of care.  

Early intervention and timely disease management prevents unnecessary hospitalizations by identifying high-risk patients earlier in their care journey.  

‍7. Optimal revenue capture

By surfacing risk-adjustable HCCs, using AI for prospective risk helps ensure cost of care projections align with patient complexity.

For one large health system, AI-driven improvements in HCC coding and risk adjustment led to $18.5 million in enhanced revenue capture – resulting in a 6x return on investment.⁷