Top 10 Leading Healthcare Risk Adjustment Software to Watch in 2025

Updated on

Published on

February 7, 2025

7 min read

Team Innovaccer

List of top 10 healthcare risk adjustment software 2025

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Risk adjustment is a method that helps identify a person's health status with a code or number, which is then identified as a risk score. This code is then further evaluated to predict healthcare costs, and based on the risk score, care providers decide what kind of care should be facilitated to the patient. The “risk” to a health plan insuring members with expected high healthcare use is “adjusted” by also insuring members with anticipated lower healthcare costs.

Risk adjustment came as a response to the fee-for-service (FFS) payment model, where the payers used to pay the providers based on the services they performed for a patient. In this method, the insurance companies only get their payment reimbursed based on the value of the service they have provided or based on the needs of members and their diagnoses conducted.

What is Risk Adjustment Software?

Risk adjustment software is the tool used to analyze and predict patient data, and based on those predictions, risk score calculations are performed.

Traditional healthcare systems relied on manual workflows, which usually tend to be rigorous and time-consuming, which often lead to physician burnout. This traditional method usually forced care managers and the risk teams to indulge in the cycle of “Chat-chasing” to identify the risk and capture the evidence and the quality of data, which often resulted in decreased efficiency, high cost, and low performance.

Thus, cloud-based and integrated risk adjustment software comes as a response to these traditional and time-consuming solutions and reporting structures.

This software helps providers to identify and document suspected diagnoses at the point of care. These software can thus provide real-time data and can help in increasing transparency and closing risk gaps. This thus leads to higher reimbursement rates and better patient care.

Benefits of Risk Adjustment Software

The main purpose of risk adjustment software is to:

Analyze patient data to identify and document health conditions that affect risk scores and reimbursement calculations, particularly for Medicare Advantage and other value-based care programs
Risk Adjustment software helps ensure complete and accurate diagnosis coding by suggesting potential missing codes based on medical records, lab results, medications, and other clinical data
Track hierarchical condition categories (HCCs) which are used to predict healthcare costs and adjust payments based on patient health status
Healthcare risk adjustment assists with compliance by documenting the evidence supporting each diagnosis code and flagging potential coding issues

Benefits‍

Risk adjustment software's EHR integration is crucial for accurate cost predictions, requiring access to diverse data types (inpatient, pharmacy, SDoH) at the point of care.

While evaluating the options for the software, there are a few essential features that should be kept in consideration:

Selection of solutions with powerful integration capabilities that can effectively help in processing the data from multiple sources, ensuring exact risk assessment.
The system should efficiently identify patients at risk, which can help providers to optimize care.
The selection of an accurate payment system is crucial, as the scoring capabilities directly impact payment systems, affecting both financial sustainability and care quality.
The solution offers a standardized approach for comparing support groups, providers, and time periods which supports confident benchmarking and healthcare planning.
The software evolves with the organization, adapting to changing populations, and meeting regulatory requirements.

Discover How Healthcare Organizations Improves Resource Use and Value with Accurate Patient Risk Assignment: Read the case study

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Key considerations for choosing Risk Adjustment Vendors.

Seamless integration with EHR/claims systems using predictive analytics, which is considered to be the next big step in healthcare and different NLP for real-time risk scoring and timely interventions
Alignment with regulatory requirements (CMS/HHS) with AI-powered coding accuracy, strong audit documentation, and HIPAA-compliant security features.
Multiple risk models that help in a scalable architecture, demonstrable ROI, and proven implementation success across different segments such as Medicare/Medicaid/Commercials.
Comprehensive prescriptive and predictive analytics dashboards with capabilities that can help track and monitor, risk coding accuracy and financial outcomes.

Top 10 risk adjustment software platforms.

Innovaccer:

‍Innovaccer has been the game changer in risk adjustment and healthcare data management, emerging as a force that has been transformative and has been crucial in the transition phase of how healthcare organizations handle their risk adjustment processes. With Innovaccer’s AI assistant organization has seen a significant 70% improvement in coding accuracy and a gross benefit of $27 Million, which is clearly helping them achieve the “best platform for risk adjustment solutions. “Innovaccer’s approach goes beyond the traditional methods of viewing the patient's care journey, this is done by priortizing and making the healthcare experience both efficient and accurate.

‍Innovaccer’s Platform’s success in risk adjustment is driven by three strategic advances:

Healthcare AI Platform

Every Innovaccer application is powered by Innovaccer's Healthcare AI Platform which unifies patient data across systems and care settings and empowers healthcare organizations with scalable, modern applications that improve clinical, financial, operational, and experiential outcomes.

Patient 360

Helps provide a 360-degree view profile of patients that is created on top of the Innovaccer Healthcare AI Platform that gives a unified single view of patients, along with appointment details, clinical history, medication history, etc.‍

Why do Innovaccer’s risk adjustment solutions stand out in the market?

The solutions help in performing continuous retrospective analysis to capture missed and suspected codes
It helps to unify data for accurate risk stratification
It helps in analyzing real-time data and capturing codes to identify and close care gaps
Provides a data analytics dashboard to track the performance and identify opportunities for optimization

Try Innovaccer’s Risk Adjustment Solution Now

Book a demo to learn how we can enhance efficiency, improve risk assessment, and optimize health plans.

‍The future of healthcare analytics is poised for transformative advancements. With the introduction of artificial intelligence, machine learning, and big data integration, healthcare analytics is expected to advance. As healthcare organizations increasingly use predictive analytics, personalized treatment plans will become more common. This will enhance patient outcomes and help them make informed decisions on treatments. Real-time data access will enable informed decision-making, while operations among systems will improve care coordination. Additionally, telemedicine and wearable technology advancements will generate vast amounts of data. This is expected to allow healthcare providers to identify trends and optimize operations, leading to a more efficient, patient-centered healthcare system.