Retrospective Chart Reviews for Risk Adjustment
Lift HCC recapture from 70-75% to 90%+ and assemble audit-ready response packets in under 24 hours. QuickIntell helps risk adjustment teams find missed HCCs, validate MEAT evidence, apply hierarchy, and finalize RAF-ready reviews faster.
Under the hood, Computer Vision, OCR, and NLP convert scanned charts, PDFs, and clinical notes into structured evidence for coder and clinical reviewer sign-off.
TL;DR
At a glance for retrospective chart reviews.
- Capture every defensible HCC across last year's charts.
- CMS-HCC v22/v24/v28 selected per patient, hierarchy applied, audit trail attached.
- Recapture rate 70–75% → 90%+; audit packet in <24h.
How it Works
EHR encounter → ICD-10 → MCE → Crosswalk → Hierarchy → Coefficient → RAF → Human Review → Sign Off → CMS
- 1
EHR encounter
A closed encounter starts the retrospective review flow.
- 2
ICD-10
Patient demographics and diagnosis codes are ingested.
- 3
MCE
Age and sex validation drops invalid codes with a logged reason.
- 4
Crosswalk
Valid ICD-10 codes map to CMS-HCC categories.
- 5
Hierarchy
CMS exclusions suppress lower-severity related HCCs.
- 6
Coefficient
Segment and model coefficients are selected.
- 7
RAF
RAF is calculated and normalized for the payment year.
- 8
Human Review
Configured cases route to coder and clinical review.
- 9
Sign Off
Reviewer approval locks the final score and evidence.
- 10
CMS
Final captures feed RAPS/EDPS package generation.
What's Inside
Retrospective review teams can start with the core risk-adjustment tools needed to validate evidence, finalize RAF scores, and preserve a defensible submission trail.
HCC Crosswalk Viewer
Search ICD-10 to HCC mappings with model, hierarchy, and coefficient context.
Human Review Queue
Route suspected, high-impact, or policy-required HCCs to coder and clinical sign-off.
Recapture Gaps Analytics
Rank prior-year chronic HCCs missing this year by RAF impact and outreach priority.
RAPS/EDPS file generator
Package finalized captures into CMS-ready submission files with unreviewed jobs excluded by default.
Audit trail
Preserve source encounter, ICD-10, model, hierarchy, evidence, reviewer, and timestamp for every HCC.
EHR write-back
Send finalized HCC lists, RAF scores, and care-management flags back to connected clinical systems.
OpenEMR integration
Ingest patient and encounter context from OpenEMR and write reviewed risk profiles back where configured.
KPIs / Outcomes
The operating model is built around recapture lift, reviewer throughput, audit speed, and submission-ready evidence.
90%+
Recapture target for chronic HCCs
40-50
Charts per coder per day with automation
Under 24h
Audit response packet assembly target
v24/v28
Model blend and hierarchy traceability
Recapture-lift scenario
For a 5,000-life Medicare Advantage panel, moving from a 70-75% recapture baseline toward a 90%+ target represents $1.4M-$2.6M in annualized incremental revenue.
Trust & Compliance
Retrospective reviews touch PHI, payment evidence, and audit defensibility. QuickIntell keeps each HCC capture tied to access controls, encryption, and a complete reviewer trail.
Review security controlsHIPAA-ready PHI controls
Protected health information is governed through customer agreements, tenant scoping, and healthcare-specific administrative and technical safeguards.
SOC 2 Type II program evidence
Security program evidence aligns with SOC 2 Type II reporting and AICPA Trust Services Criteria for operational controls.
HITRUST CSF control mapping
Risk-adjustment workflows are mapped against HITRUST CSF control expectations for healthcare security and compliance review.
Encrypted in transit and at rest
Chart files, extracted evidence, and reviewer activity are protected with encryption while moving between systems and while stored.
RBAC and least privilege
Role-based access limits who can view PHI, accept or reject HCCs, approve RAF results, export packets, and manage submission batches.
Audit log per HCC capture
Every accepted, modified, rejected, or suppressed HCC records the source encounter, code, model, hierarchy decision, reviewer, and timestamp.
Composite MA / ACO proof point
5,000-life MA panel: recapture lift from 73% toward 91%, annualized incremental revenue in the $1.4M-$2.6M range, and clinical review cycles compressed from days to under 48 hours.
Illustrative operating pattern; no named customer is approved or implied.
Browse resources and case studiesCustomer Segments
Medicare Advantage plans
Run retrospective sweeps across MA cohorts, prioritize missing chronic HCCs by RAF impact, and prepare audit-ready capture evidence during the v28 transition.
Payor solutionsACO REACH & MSSP groups
Close risk gaps for attributed lives, coordinate provider outreach, and maintain defensible HCC evidence for value-based performance reporting.
MSO and ACO solutionsRisk-bearing physician groups & MSOs
Focus limited coder and clinician time on high-value charts, route CDI questions to providers, and track recapture progress across practices.
Provider solutionsRCM partners serving MA cohorts
Standardize batch chart reviews, reviewer queues, RAPS/EDPS package generation, and client-ready audit exports across multiple payer populations.
Analytics solutionsIntegrations
Retrospective review work connects upstream chart evidence, coding decisions, and downstream claim or submission workflows.
EHR
Ingest demographics, encounters, chart documents, and provider context from connected clinical systems.
Coding
Pass reviewed HCC evidence into coding and documentation review workflows for downstream consistency.
Claims
Package finalized captures for RAPS/EDPS files, claim context, and audit exports.
Frequently Asked Questions
How does QuickIntell handle the v28 phase-in?
QuickIntell applies the configured CMS-HCC model mix for each payment year, including the v24/v28 phase-in and 100% v28 scoring for 2026. Reviewers see the model version, normalization factor, hierarchy decisions, and coefficient logic behind each RAF result.
Does it submit RAPS/EDPS directly to CMS?
QuickIntell generates CMS-ready RAPS/EDPS files from finalized, reviewed HCC captures. Direct submission can be enabled through the configured integration; otherwise teams can download the files and submit through their existing CMS or clearinghouse process.
How are MEAT-failing HCCs handled?
Suspect HCCs that do not meet Monitor, Evaluate, Assess, Treat evidence are held for review or rejected with a documented reason such as insufficient documentation, Excludes1 conflict, wrong patient, or other. The RAF score is recalculated and the rejection is preserved in the audit trail.
What happens for ESRD or dual-eligible patients?
Patient demographics and status flags, including dual-eligible, disabled, institutional, ESRD, and ESRD status, drive segment selection before coefficient lookup. If a patient transitions into ESRD, the patient profile and job log show the segment change used for RAF scoring.
How is hierarchy applied?
QuickIntell applies CMS hierarchy rules after ICD-10 to HCC mapping and before final RAF calculation. More severe related HCCs suppress less severe categories, and reviewers can trace which HCC counted, which one was suppressed, and why.
How fast is implementation?
Implementation starts with the EHR or chart source, patient demographics, CMS-HCC model settings, reviewer permissions, and sample chart validation. Simple cohorts can begin controlled retrospective review after those feeds and workflows are configured; exact timing depends on source-system access and validation scope.
Can it integrate with OpenEMR / Epic / Athena?
Yes. QuickIntell is designed for EHR integration patterns that include OpenEMR, Epic, Athenahealth, and other common clinical systems. Retrospective review workflows can ingest demographics and chart evidence, then write back HCC lists, RAF scores, or care-management flags where supported.
How is RADV audit prep handled?
Every captured HCC links back to the source encounter, ICD-10 code, model version, hierarchy decision, MEAT evidence, reviewer identity, and timestamp. Those records can be assembled into audit response packets instead of recreated manually during RADV or payer review.
What's the recapture lift typical?
Many Medicare Advantage practices operate around 70% to 75% recapture, while the achievable benchmark is 90% or higher. QuickIntell focuses reviewers on prior-year chronic HCCs that are missing this year, ranked by RAF impact, so lift depends on starting performance and provider follow-through.
How is PHI protected?
QuickIntell uses HIPAA-aligned safeguards with encryption in transit and at rest, role-based access control, tenant scoping, and audit logging for sensitive actions. PHI handling is governed through customer agreements and security controls designed for healthcare operations.
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