Health Plans + Payers

Delivering the value-based future today.

Achieve Payer Excellence with Prospective Risk Adjustment and Advanced Analytics

Navigating cost and quality: A balanced approach Thrive in the dynamic landscape of value-based care with Veradigm’s state-of-the-art health plan payer solutions that help you turn challenges into catalysts for growth. Choose a full comprehensive solution or select from multiple capabilities, including advanced analytics, precise risk adjustment, and systematic data exchange. This flexibility simplifies operations, boosts provider engagement, and drives exceptional member health outcomes—all while keeping costs in check.

Gap Closure

Closing care gaps is essential for both successful patient outcomes and boosting revenue. Missed screenings, incomplete documentation, and abandoned prescriptions create challenges that risk patient health and leave financial opportunities on the table. Veradigm addresses these challenges with a method that combines prospective services, real-time alerts, and active collaboration.

Gap Closure Services

Veradigm’s Gap Closure Services—powered by our CORE Program (Comprehensive Outcomes Realization and Engagement)—support providers in taking gap closure to the next level by delivering services to identify, close, and document care gaps for your network providers, helping your health plan realize improved patient outcomes and additional revenue.

Equip providers: Proactively bridge care gaps and optimize outcomes with clinical services.
Prioritize interventions: Use digital integration, patented risk adjustment, and quality analytics to focus on high-impact areas—including annual physicals, immunizations, and preventive screenings.
Deliver results: Enrich patient health, improve care quality, and secure maximized reimbursements to generate measurable ROI.

Care Gap Alerting

Veradigm Payer Insights integrates patient-specific care gap alerts directly into the EHR workflow of your network providers. It delivers real-time, actionable insights to help them identify and address care gaps immediately, improving care, streamlining operations and reducing administrative overhead:

Real-time alerts: Display patient-specific gaps directly within the Electronic Health Record (EHR) for more timely interventions during regular visits.
Seamless integration: Plug into existing clinical workflows to reduce manual tasks for more informed care decisions.
Increase efficiency: Reduce follow-up frequency and administrative burdens through a unified alerting system.

Provider Engagement Solutions

Veradigm Collaborate increases provider engagement by facilitating communications and lowering alert fatigue. Here’s how it provides your team with actionable, prioritized insights:

Strengthens communication: Consolidate alerts for risk adjustment, quality, and pharmacy opportunities into one, efficient interface.
Minimizes alert fatigue: Customize prioritization algorithms and deliver only high-confidence alerts to fit easily into provider workflows.
Fuels effective engagement: Use intuitive dashboards, provider report cards, and secure self-service portals to identify the best opportunities for outreach and accelerate gap closures.

Together, these three pillars create a powerful strategy that promotes care quality, raises operational efficiency, and amplifies revenue recovery. From detection to intervention with Veradigm’s Gap Closure solutions, every step is automated to support superior patient outcomes and financial performance.

Risk Adjustment

Balancing superior patient care with cost control is an ongoing challenge for healthcare payers. Our integrated risk adjustment solutions convert complex clinical and financial data into actionable insights that align finance, medical management, and actuarial teams. They also support clinical quality and secure financial sustainability in today’s value-based care environment.

Risk Adjustment Analytics

Convert complex clinical and financial datasets into clear, actionable insights. Our Risk Adjustment Analytics offers precise scoring, predictive insights, and live oversight to help your teams pinpoint intervention opportunities and optimize risk management strategies across multiple care markets.

Precision scoring: Consolidate clinical and financial data to generate accurate risk scores that capture chronic conditions and unsubmitted diagnoses.
Predictive insights: Apply advanced algorithms, big data mining, and multiple predictive models to prioritize intervention opportunities across Managed Medicaid, ACA Commercial, and Medicare Advantage markets.
Real-time oversight: Take advantage of dynamic dashboards to monitor gap closures, risk adjustment revenue, and performance against Key Performance Indicators.

Health Equity

Develop a broad view of member health by incorporating non-medical drivers (NMDoH) into your strategy. Our Health Equity approach uses demographic and socioeconomic data to uncover hidden disparities, so you can design targeted interventions for meaningful population health outcomes.

Reveal disparities: Draw on NMDoH data—such as housing, transportation, food security, education, and employment—to identify at-risk members and reveal overlooked gaps in care.
Tailored interventions: Apply holistic insights from non-medical factors to craft personalized care plans that address the root causes of health disparities.
Improve outcomes: Increase population health management, heighten member satisfaction, and meet regulatory standards while reducing complications and long-term healthcare costs.

Risk Mitigation

Shield your organization from the financial fallout of data validation audits with proactive risk management. When our Risk Mitigation solution identifies high-risk conditions and providers, it delivers actionable alerts that help you take preemptive measures and safeguard your financial health.

Preempt audit risks: Identify and quantify the conditions and providers who are putting the plan at risk.
Actionable alerts: Provide targeted, confidence-adjusted risk estimates to back research, correction, and provider education initiatives without increasing false negatives.
Guard financial health: Serves as the “voice of caution” to manage audit risk and help your plan secure its fair share while mitigating costly errors.

Data Exchange & Coding

Modern healthcare hinges on drawing on accessible, accurate data and converting it into actionable intelligence. Veradigm’s integrated suite redefines how medical charts are retrieved, coded, and analyzed. It delivers faster results, improved accuracy, and actionable insights for smarter, more efficient care across your network.

eChart Courier

Imagine eliminating the cumbersome manual process of “chart chasing.” eChart Courier automates medical chart retrieval and delivery and is used by more than 300,000 healthcare providers to send and receive charts in a secure electronic format. It helps health plans and providers:

Automate retrieval: Cancel manual chart retrieval, saving time and reducing labor demands.
Improve data sharing: Deliver patient charts securely and accurately with encrypted transmission that adheres to HIPAA standards.
Improve operational efficiency: Free up staff to focus on patient care rather than administrative tasks.
Increase accuracy: Ensure correct patient matching and detailed reporting for full traceability.

eChart Courier redefines the chart retrieval process and maximizes clinical data exchange to pave the way for rapid decision-making and better patient outcomes.

Quality Management

Quality is the cornerstone of effective healthcare. We don’t just detect gaps; we give you the tools to act decisively. Veradigm’s Quality Analytics converts diverse data sets into clear, actionable insights that help health plans uncover unmet care needs in medical, dental, pharmacy, and additional benefit areas. These insights then ignite significant improvements in performance.

Proactive alerts: Identify members with open care gaps using precision patient care analytics.
Efficient workflows: Seamlessly integrate with existing systems to prioritize high-impact interventions.
In-depth reporting: Generate customizable reports in CSV and TXT formats for effortless visualization and analysis.
Integrated decision-making: Leverage real-time insights from Veradigm Payer Insights to inform timely, effective actions.