Dynamic Prospective Risk Adjustment for Advanced Provider Engagement
HealthEdge delivers a sophisticated, technology-driven approach to Provider Engagement Coordination (PEC) that empowers your provider network with next-generation workflow integration and risk score accuracy. Unlike fragmented point solutions, our comprehensive suite of solutions seamlessly bridges the gap between payer strategic goals and clinical realities. By synchronizing data at the point of care, we drive precise risk adjustment and quality improvements, elevate HEDIS® performance, and close critical clinical gaps across Medicare Advantage, Affordable Care Act (ACA), and Medicaid populations.
Our architecture is designed for true interoperability, creating a single source of truth for provider data. We provide the flexible infrastructure necessary to meet providers where they operate to minimize abrasion and maximize compliance.
Strategic Objectives and Key Outcomes
The HealthEdge Provider Engagement Coordination (PEC) ecosystem is engineered to solve complex operational challenges by leveraging automated intelligence to identify high-risk clinical flags and preventive care measures. This systematic, prospective approach is a key lever for driving Star Rating performance and improved health outcomes.
|
Metric |
Program Average |
Impact on Health Plans |
|
Return on Investment (ROI) |
3:1 |
Delivers significant financial returns on program investment. |
|
Risk Accuracy Improvement |
10-15% |
Enhances the precision of risk scores for better financial forecasting. |
|
HEDIS® Measure Improvement |
5% |
Boosts quality scores and performance metrics. |
Advanced Delivery Models for Maximum Interoperability
Our solution creates a single source of truth for provider data, streamlining ingestion and enrichment through multiple delivery channels designed for maximum interoperability.
1. Electronic PEC: Integrated Point-of-Care Solutions
- Mechanism: Real-time integration with major EMR systems delivers Clinical Documentation Improvement (CDI) alerts at the point of care.
- Technology: The ePEC browser provides a secure, web-based portal for providers to address gaps and manage alerts efficiently.
- Impact: Simplifies workflows, reduces administrative burden, and accelerates the closure of documentation gaps and high-risk flags.
2. Remote PEC: Digital Extension for Distributed Networks
- Mechanism: A flexible solution designed for provider networks that are geographically dispersed or have limited EMR infrastructure.
- Technology: Delivers CDI alerts and coder reviews through provider-preferred digital channels, ensuring consistent engagement.
- Impact: Ensures comprehensive coverage and support for all practices, maintaining high standards of data accuracy across the entire network.
3. On-Site PEC: Expert Clinical Collaboration
- Mechanism: Deploys certified coding experts directly into provider offices within large group settings in dense geographical areas.
- Technology: Facilitates peer-to-peer collaboration and real-time education on medical record documentation requirements.
- Impact: Enhances provider knowledge and compliance through direct, expert-led support.
The HealthEdge Advantage: Automation and Compliance
We empower health plans to be nimble enough to address future regulatory changes while optimizing current performance. Our platform is built on three core pillars:
- Automated Intelligence: We queue CDI alerts for undocumented conditions from prior years, using predictive insights to address potential gaps before they become issues.
- Concurrent Review: Clinical gaps are addressed during the provider encounter and concurrently reviewed by certified coders, ensuring data integrity and immediate feedback.
- Seamless Interoperability: Our initiatives are designed to integrate with all major EMR systems, minimizing disruption and maximizing efficiency.
Creating Value Across the Healthcare Ecosystem
Our PEC solutions deliver measurable value to health plans, providers, and members, creating a more connected and efficient healthcare experience.
For Health Plans:
- Risk Adjustment Precision: Improve risk score accuracy and reduce CMS RADV audit exposure.
- Performance Metrics: Enhance HEDIS® measure scores and achieve higher Star Ratings through prospective gap closure.
- Clinical Intelligence: Leverage automated delivery of clinical high-risk flags and chronic condition identification to stay ahead of payer priorities and industry disruption.
For Providers:
- Workflow Efficiency: Utilize intuitive tools that integrate directly with EMRs, removing the need for "swivel-chair" data entry.
- Reduced Friction: Work within existing practice workflows to minimize administrative overhead and improve provider relationships.
- Education & Support: Gain access to experienced teams that understand clinical nuances and provider needs.
For Members:
- Care Quality: Improved medical record documentation directly correlates to better patient health outcomes.
- Continuity of Care: Enhance support for the provider/member relationship through accurate and timely data.
- Superior Experience: Drive a better quality of care and improved health outcomes, leading to a superior member experience and satisfaction.
