Agentic AI at the Helm: Precision Risk Adjustment for Payers
Accelerate risk adjustment cycles, boost coder productivity and optimize operating costs by 50% with Persistent’s Agentic AI.
For payers, risk adjustment is no longer just a back-office function, it determines revenue integrity, plan competitiveness and regulatory survival. Yet most Medicare Advantage and Affordable Care Act (ACA) programs still run on manual chart review and fragmented workflows that inevitably miss hierarchical condition categories (HCCs), slow teams down and invite audit risk.
Persistent’s Risk Adjustment solutions, powered by our ProcessIntel Agentic AI accelerator, are built to address such gaps. We deploy collaborating AI agents across the entire retrospective lifecycle: automatically retrieving medical records, extracting diagnoses from unstructured charts, mapping ICD-10 codes to HCCs, validating documentation and compliance and assembling audit-ready evidence, while routing only the most complex exceptions to human coders.
We deliver higher risk-adjusted factor (RAF) accuracy, more predictable revenue, materially lower compliance and audit exposure, and 40–50% reduction in operating costs with a step-change in coder productivity.
For payers looking to modernize risk adjustment fast, with scalability, explainability and full traceability back to clinical evidence, Persistent is the partner to put at the top of the list.
Benefits
- Improved RAF Accuracy: AI-driven diagnosis extraction and HCC mapping enable comprehensive, consistent risk capture.
- Revenue Protection & Uplift: Closes risk gaps and strengthens member risk stratification helping safeguard Risk Adjustment revenue.
- Up to 50% Cost Reduction: End-to-end automation delivers 40–50% reduction in operational and coding costs.
- Higher Productivity & Faster Cycles: Increases coder throughput while accelerating chart review, coding and evidence preparation.
- Audit-Ready Compliance: Explainable, traceable AI outputs with clear evidence linkage reduce audit risk and rework.
Why Persistent?
Deep Healthcare Payer Domain Expertise
Proven understanding of US risk adjustment, RAF, HCC coding, CMS requirements and audit expectations, grounded in real payer use cases.
End-to-End Agentic AI Approach
Goes beyond point solutions with multiagent orchestration across chart retrieval, coding, compliance checks, evidence packaging and human review.
Built on Reusable AI IPs
Leverages Persistent IP, ProcessIntel (agentic process automation) and DocIntel (document intelligence), to accelerate time-to-value and scale reliably.
Explainable and Audit Ready by Design
Every AI recommendation is traceable to clinical evidence, supporting CMS RADV audits and reducing compliance risk.
Proven Business Impact at Scale
Higher RAF accuracy, 40–50% cost reduction, improved coder productivity and faster risk adjustment cycles.
FAQs
Agentic AI automates diagnosis extraction from unstructured medical charts and maps ICD-10 codes to HCCs with consistency, reducing missed diagnoses and coding variability inherent in manual processes. Persistent’s solution orchestrates intelligent agents across the retrospective lifecycle, ensuring comprehensive risk capture while maintaining full traceability to source clinical evidence for audit readiness.
Persistent’s solution maintains full traceability to source clinical evidence for every HCC mapping, producing explainable AI outputs with clear evidence linkage that reduce audit risk and rework. The system packages audit-ready documentation while validating compliance throughout the coding process, ensuring diagnoses meet regulatory standards for Medicare Advantage and ACA programs.
Persistent’s solution seamlessly integrates human review where it matters most, allowing coders to focus on complex clinical scenarios and validation rather than routine extraction tasks. This approach increases coder throughput and productivity while the AI handles high-volume, repetitive diagnosis capture and HCC mapping across the retrospective lifecycle.
The solution orchestrates intelligent agents to retrieve medical records and integrate across payer systems as part of the end-to-end automation. Persistent’s approach ensures seamless connectivity with existing clinical data repositories while maintaining data integrity throughout the diagnosis extraction, coding and evidence preparation workflow.
Unlike rules-based NLP tools, Persistent’s Agentic AI orchestrates multiple intelligent agents across the entire retrospective lifecycle rather than addressing isolated coding tasks. The solution moves beyond simple extraction to deliver end-to-end automation with explainability, continuous learning and audit-ready evidence packaging that traditional NLP approaches cannot achieve.
The solution maintains clear evidence linkage for every coded diagnosis, providing explainable AI outputs with full traceability back to source clinical documentation. Persistent’s approach packages audit-ready evidence throughout the process, ensuring payers can demonstrate compliance and reduce rework when facing regulatory scrutiny or CMS audits.
Contact us
(*) Asterisk denotes mandatory fields
