Matrix Medical Network and HealthFair just agreed to pay $56.5 million to settle False Claims Act allegations tied to risk adjustment — diagnoses submitted without supporting documentation, codes drawn from patient attestation alone, conditions contradicted by the clinical record.

It’s a useful reminder for us in PACE: if a diagnosis can’t be substantiated in the chart, it shouldn’t be on the claim. The good news is that the path to audit-ready coding is well-worn, and IRIS risk adjustment makes it the default.

How IRIS keeps every HCC audit-ready

IRIS is built around a review-and-query loop that catches documentation gaps before they become compliance risk.

Review

Every condition that maps to an HCC is reviewed against the supporting documentation. If the record doesn’t substantiate the diagnosis, it’s flagged so no condition slips through unchecked.

Query

When documentation is insufficient or unclear, our coding team initiates a query process with the provider.

Providers have 48 hours to respond. Based on their response, the record is either amended and coded with the amendment, or coded as-is — and every CMS-payable condition lands on the claim backed by documentation that will hold up to a RADV audit.

While IRIS works with any EMR, CareHub EMR customers get the added benefit of the entire query workflow living inside the EMR. No more missed emails, no more chasing clarifications across systems.

What that means for your program

With IRIS handling review and query, PACE teams get:

• CMS-paid conditions that are audit-ready, every time
• Providers learning documentation best practices in real time
• Coders and providers actually communicating — in the system they already work in
• More accurate clinical records, which strengthen participant care and financial outcomes together

Risk adjustment is too important to leave to chance, and you shouldn’t have to navigate it alone. Request a demo and we’ll walk you through how IRIS keeps your program clear, confident, and compliant.