Live Agent Demo

RAF Score Optimization Agent

Watch an agent audit member RAF scores against clinical evidence, surface coding gaps and over/under-coded conditions, generate compliant HCC addendum documentation, and maximize revenue accuracy — fully autonomous.

Agentic AI Classical + GenAI Simulated
Domain Risk Adjustment · Stars Quality
Steps 6
Runtime <3 min
AI Type Agentic + GenAI
Member RAF Audit Queue
Scanning
agent > load_raf_queue(plan="SilverCare MA", year=2025, batch_size=6, sort_by="gap_desc")
Member ID Name Age Current RAF Expected RAF Gap Flag
MA-00112 Flores, A. 71 1.42 2.18 +0.76 Undercoded
MA-00287 Nguyen, T. 72 2.87 2.91 +0.04 Review
MA-00334 Adams, J. 69 3.21 2.85 -0.36 Overcoded
MA-00198 Castillo, E. 79 1.18 2.34 +1.16 Undercoded 🔴
MA-00502 Murphy, K. 74 2.05 2.12 +0.07 Review
MA-00441 Rivera, D. 67 1.95 2.67 +0.72 Undercoded
6 members in queue · 3 undercoded · 1 overcoded · Est. revenue at risk: $47,200/yr
Clinical Evidence Mining
Mining
agent > mine_clinical_evidence(member_id="MA-00198", sources=["claims","ehr","labs","specialist_notes"], year=2025)
Castillo, E. (MA-00198) — Clinical Evidence
Age 79 · Current RAF: 1.18 · Expected RAF: 2.34
Undercoded +1.16
Current HCC codes on file
HCC 85 — CHF HCC 108 — Vascular Disease HCC 22 — Diabetes, no complications
Conditions NOT currently coded
🔴
HCC 23: Diabetes with Chronic Complications
Labs show HbA1c 9.1%, nephropathy diagnosis in encounter notes (Mar 2025). ICD-10: E11.65
🔴
HCC 137: Chronic Kidney Disease Stage 3–5
eGFR 32, Creatinine 2.1, CKD Stage 3b confirmed by nephrologist note (Jan 2025). ICD-10: N18.32
🟡
HCC 18: Diabetes with Ophthalmologic Complications
Retinopathy noted in ophthalmology report (Feb 2025). ICD-10: E11.319
🟡
HCC 21: Protein-Calorie Malnutrition
Albumin 2.9 g/dL, malnutrition noted in hospitalist note. ICD-10: E44.0
🟢
HCC 96: Specified Heart Arrhythmias
Atrial fibrillation in cardiology notes (uncertain if chronic). ICD-10: I48.91
Evidence sources: 14 encounter notes · 3 lab panels · 2 specialist letters
4 high-confidence HCC gaps identified. HCC 23 and HCC 137 are the highest-value opportunities — both clinically supported by lab and specialist documentation.
HCC Gap Validation
Validating
agent > validate_hcc_gaps(member_id="MA-00198", threshold=0.70, apply_hierarchy=true, cms_year=2025)
HCC Condition Evidence Clinical Support Confidence Action
HCC 23 DM w/ Chronic Complications Strong HbA1c 9.1% + nephropathy dx
97%
ADD
HCC 137 CKD Stage 3b Strong eGFR 32, nephrologist letter
95%
ADD
HCC 18 DM w/ Ophthalmologic Compl. Moderate Retinopathy report
82%
ADD w/ review
HCC 21 Protein-Calorie Malnutrition Moderate Albumin 2.9, hospitalist note
74%
ADD w/ review
HCC 96 Atrial Fibrillation (spec.) Low Single cardiology note
51%
Flag for physician
HCC 22 DM without complications Conflict Superseded by HCC 23 — Remove (superseded)
HCC 23 + 137 alone +0.94 RAF
Full scenario +1.16 RAF
Expected RAF 2.34
Validation complete. 4 addable HCCs confirmed with ≥74% clinical confidence. HCC 22 flagged for removal — superseded by HCC 23 per CMS hierarchy rules.
Addendum Documentation Generation
Generating
agent > generate_addendum(member_id="MA-00198", hcc=23, evidence_ids=["lab-2025-0303","neph-letter-0114","enc-2025-0307"])
Physician Addendum — HCC 23 | Member MA-00198
Patient Castillo, Elena
DOB 1946-02-28
Member ID MA-00198
Condition Diabetes Mellitus with Chronic Kidney Disease
ICD-10 E11.65
Clinical Basis
Patient has documented Type 2 Diabetes Mellitus (E11.9) with concurrent CKD Stage 3b (N18.32) confirmed by nephrology evaluation dated January 14, 2025. HbA1c measured at 9.1% on March 3, 2025 indicates ongoing poor glycemic control. Nephropathy diagnosis documented in encounter notes of March 7, 2025 by Dr. Patel, Summit Nephrology.
Supporting Documentation
Lab report Mar 3 Nephrology letter Jan 14 Encounter note Mar 7
“I attest that the above condition was present, assessed, or treated during the measurement period.”
Physician Signature / Date
Generated by NestedLoop RAF Agent · CMS-compliant · Pending physician signature
HCC 23 addendum drafted. Document routed to Dr. Patel’s signature queue via EHR integration. Estimated signature turnaround: same business day.
Overcoding Remediation — Adams, J.
Remediating
agent > remediate_overcoding(member_id="MA-00334", flags=["HCC-136","HCC-19"], action="flag_for_review")
Adams, J. (MA-00334) — Overcoding Case
Age 69 · Current RAF: 3.21 · Expected RAF: 2.85
Overcoded -0.36
Current HCC codes on file
HCC 85 — CHF HCC 108 — Vascular Disease HCC 19 — DM Acute Complications HCC 55 — ESRD HCC 136 — CKD Stage 5
Agent finding: HCC 55 (ESRD) and HCC 136 (CKD Stage 5) cannot coexist per CMS hierarchy — ESRD supersedes CKD. Additionally, HCC 19 (Acute complications) has no supporting documentation found in 2025 encounters. Prior year carry-forward applied erroneously.
Remediation actions
Remove HCC 136: Superseded by HCC 55 (ESRD)
Per CMS hierarchy rules, ESRD (HCC 55) supersedes CKD Stage 5 (HCC 136). Simultaneous submission creates audit risk and potential recoupment.
RAF: -0.21
Flag HCC 19: No 2025 clinical support
No 2025 encounter supports acute DM complications. Prior year carry-forward applied erroneously. Recommended for physician review for deletion.
RAF: -0.15
Corrected RAF (if both removed) 2.85
Audit penalty savings $3,100
Overcoding corrections flagged. HCC 136 conflicts with HCC 55 per CMS diagnosis hierarchy. HCC 19 has no 2025 encounter support. Proactive correction reduces audit exposure.
Batch Summary & Revenue Impact
Complete ✓
RAF Audit Batch Complete

6 members audited — 11 HCC gaps found, 6 addenda generated, 2 overcoding issues flagged. Net revenue impact: +$27,800 annually.

6 Members audited
11 HCC gaps found
6 Addenda generated
2 Overcoding flags
Member RAF Before RAF After Annual Impact
Castillo, E. 1.18 2.34 +$14,400
Flores, A. 1.42 2.18 +$9,100
Rivera, D. 1.95 2.67 +$8,600
Adams, J. 3.21 2.85 -$4,300
Total est. annual revenue correction +$27,800
Compliance: All addenda CMS-compliant. Overcoding corrections reduce audit recoupment risk.
Time: Manual RAF review time estimated: 6.5 hrs. Agent completed in 2.8 minutes.
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Disclaimer: This is an interactive demonstration using simulated data and pre-scripted AI responses. No real patient, member, or provider data is used. All values are fictional and for illustrative purposes only. Real deployments include full HIPAA compliance, SOC 2 audit controls, CMS regulatory adherence, and clinical review oversight.

Proprietary assets of NestedLoop LLC. Reproduction or re-use with explicit consent and authorization from NestedLoop LLC only.