Risk Adjustment & Quality
with AI-native Clinical Precision
Unified AI-native platform for Concurrent Risk Adjustment, HCC suspecting, Clinical validation, Quality gap closure, encounter data reconciliation, RADV audit readiness and Compliance.Designed to cover end-to-end Medicare risk adjustment operations for Medicare Advantage plans and Value-based care entities with low operational spend, boosting compliance and enhancing margins by bending the curve on medical-loss ratio.
PROBLEM
Four Questions for
Risk Adjustment
VBC Program Leaders
- How much RAF score under- or over-reporting is happening in encounter data?
- Will the RAF score defense stand clinical validation review in a RADV audit?
- Is capturing of chronic HCC capture helping in lower utilization or eroding margins?
- Where is RAF score accuracy slipping while quality gaps stay open?
Overall Big Question
Is your VBC program designed to capture RAF score accurately, meeting risk adjustment compliance goals, decreasing utilization, improving margins?
CORE CAPABILITIES
Risk and Quality Unified by Clinical AI and Smart Automation
Clinical AI-native reasoning, CMS & HHS HCC rules engine, Quality measure care gap logic, and claims data reconciliation converge in one unified smart workflow – transforming legacy risk adjustment from retrospective chart chasing into concurrent & prospective mode, to accurately capture RAF score and Quality measure score, with fully RADV audit ready design that meets the regulatory compliance framework.
Autonomous HCC Coding and Compliance
Clinical AI engine converts clinical evidence into HCC codes, automating HCC capture – backed with clinical validation, meeting coding compliancePrior year and current year, closed together
Data Reconciliation with RAF Gap Prioritization
Encounter data reconciliation embedded in RAQ+ prioritizes high RAF delta and PMPY impact into high-value targets, speeding up time to action Smart prioritization, faster action
Quality Measure Care Gap Logic
Quality care gaps are calculated population-wide, with quality measure compliance captured on every record, reducing friction, reducing care gapsQuality measured alongside RAF score capture
Predictive Risk Modeling
Clinical AI reasoning surfaces untapped prior-year conditions and current-year suspects within same payment year, capturing RAF score accuratelyHighest-value charts, first
RADV Audit Readiness
audit-vulnerabilities to HCC auditors throughout the
payment yearAudit risk, flagged early
Human-in-the-Loop Review
A built-in QA workflow lets human auditors review the AI-generated evidence behind every recommendation, resolving objections before a claim ever reaches CMSAuditors validate, AI accelerates
Modern VBC Infrastructure that Fortify
Compliance and Improves Margins
RAQ+ provides an intelligent automation framework with, smart analytics that decreases OpEx, meets HCC coding compliance checks, transforms the legacy risk adjustment operations into an ultra-modern AI-native platform
100%
HCC gap
recapture
50x
Productivity & Efficiency
50%
Reduction in Coding & analytics spend
100%
RADV audit
readiness
5-10mins
HCC reviews across
multiple DOS
*Based on client implementations, health system pilot outcomes, and operational modeling. Results vary by organization
WHY RAQ+
Human and
Artificial Intelligence
By harnessing the power of data analytics, automation, and AI, RAQ+ enables healthcare organizations to operate their risk adjustment and VBC programs at peak performance, reduce operational costs, stay compliant, deliver high-quality care.
Evidence-backed Autonomous diagnosis coding & HCC capture
Human-in-the-loop Diagnosis capture with clinical validation
Fully auditable, traceable, RADV-compliant workflows
Compliance-first
by design
KEY FEATURE
AI-native Platform for
Defensible Future of VBC
Multi-agent AI reaches every step of VBC operations, from the HCC coding engine for RAF capture, to medical loss ratio control – expanding operational capacity without expanding FTE headcount
AI Engine for
Coding and Analytics
Diagnostic inference, HCC classification, and clinical validation are driven by clinical LLMs and Vertex AI, delivering efficiency in RAF and HEDIS capture alike
Coding and clinical validation, one workflow
Concurrent Care Gap
and Quality Closure
Quality AI care gap logic and consistent quality care gap capture run alongside risk adjustment, aligning population risk monitoring with quality performance
Quality that keeps pace with the plan year
Utilization and
Cost Intelligence
Leakage identification, medical claims monitoring, and pharmacy expense tracking, backed by predictive data for surfacing preventive visits gaps that reduce downstream inpatient admissions & re-admissions
Where margin quietly leaks
Readmissions
Reporting
LEADERSHIP DASHBOARD
For Leaders Who
Need Answers,
Not More Reports
The CAiRE+ leadership dashboard surfaces the metrics that matter most at a glance, in real time — so leaders can answer ‘what’s in it for me’ immediately.
- Real-time insights
- Actionable intelligence
- Better decisions, better outcomes
Smart Campaigns for
Medical Record Retrieval
Built-in intelligence to launch record retrieval campaigns smartly and run analytics 24×7 to avoid provider abrasion and save costs on record retrieval and vendor coding
Know when to launch and stop
the retrieval campaign
Provider Scorecards and
Performance Tracking
Built-in KPIs track VBC program progress and provider productivity across a dashboard covering RAF scores, HEDIS, and Star Ratings
Program progress, in real time
Interoperability and
Real-Time Data Access
SMART on FHIR, HL7 API services carry real-time EMR data for AI-powered clinical assessment while BigQuery and Firestore power metadata with intelligent AI analytics
Connected to what you already run
AUTONOMOUS HCC CODING AND AUDITING
Unified AI Platform for HCC Capture and RADV Audit Defense
Concurrent HCC extraction, clinical validation, and RADV audit-ready traceability with evidence support from medical records chart, making HCC diagnosis capture accurate before it ever reaches CMS, and defensible long after
1.
HCC Suspecting
Progression patterns, caught early Chronic disease progression, labs & imaging data and medication-based indicators that rules-based logic overlooks are detected by RAQ+ clinical AI2.
Concurrent Gap Recapture
One pass, both years Prior-year chronic conditions are identified alongside current-year suspects, closing HCC gaps with prospective recapture within same financial year rather than recapturing them months later through retrospective chart retrieval3.
Clinical Validation
ICD-10 coding rules, not assumptions Every extracted diagnosis maps to ICD-10-CM and HCC mapping with 95%+ accuracy, clinically validated condition by condition4.
Reviewable Audit Trail
Evidence, checked before it ships A complete audit trail accompanies each diagnosis, so auditors can review the clinical evidence behind every code before it moves downstream5.
RADV-Ready Compliance Reports
Built for CMS scrutiny HCC compliance with RADV AI intelligence for every HCC diagnosis, so RADV audit preparation draws on documentation that already exists, avoiding retrospective coding re-work5.
Documentation Quality Scoring
Where the weakness actually sits Provider scorecards analyze documentation quality and insufficiency scores at the provider level, surfacing the source of audit exposure
Get the RAQ 
Product Brochure
A complete walkthrough of the platform – capabilities,
architecture, and implementation model.
Question & Answers
Frequently Asked Questions
Deployment follows a structured model: data and EMR integration through SMART on FHIR and HL7/FHIR feeds, workflows configured to your risk and quality rules, then provider-facing scorecards and dashboards — live inside your existing operations.
Yes. A zero-trust infrastructure built on IAM and VPC Service Controls aligns with HIPAA, SOC-2, and HITRUST requirements, with end-to-end encryption, multi-factor authentication, and strict data residency controls.
Yes. It ingests PDFs, scanned images, EHR exports, and HL7/FHIR feeds, and supports SMART on FHIR for real-time EMR connectivity between payers and providers.
The shift is from retrospective chart chasing to concurrent capture — same-year HCC recapture, fewer retrospective chart reviews, and lower administrative expense, with no added headcount.
No. Repetitive chart review - ingestion, suspecting, validation, is automated, while a human-in-the-loop QA workflow keeps auditors in control of every clinical decision.
Ready to Transform Your Value-Based Care Operations?
See RAQ+ run against your own member population, charts, and quality measures.
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