Risk Adjustment & Quality Performance Management Solutions

A solution suite built on predictive analytics, machine learning, and our Intelligent Healthcare Network™ for payers that want to identify quality gaps, improve performance ratings, and increase member retention.

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Improving Quality of Care and Performance

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Value-based healthcare needs quality outcomes

Transitioning from volume to value-based care models requires payers and providers to increasingly focus on improving care management.

Understanding patients’ disease burdens, decreasing emergency room visits, shortening hospital stays, lowering readmission rates, and improving costs and outcomes associated with preventive care and complex diseases is vital to the value-based model.

To top it all off, focusing on retaining your members is a top priority and addressing risks throughout the care continuum is a necessity for maintaining the quality and performance the industry demands.


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Take action with predictive analytics insights

Utilizing industry leading machine learning and predictive analytic algorithms, we work with our customers to identify member-specific gaps in quality, care, disease status, and social determinants of health (SDOH) for Medicare Advantage, Medicaid, and commercial ACA populations. 

Our Intelligent Healthcare Network™ has processed over 12 billion health care transactions—we currently handle 1 in 5 patient records totaling $2 trillion in claims.

With the unique combination of large scale real-world data sets, sophisticated predictive analytics combined with deep subject matter expertise, we enable improved quality outcomes and performance.

 Close Risk Gaps for Better Quality Outcomes

  Identify and Understand Your Risk

Leverage our risk analytics software and support services to identify risk adjustment factor (RAF) score gaps and prioritize resources.

Our web-based software analyzes risk scores based on specific adjustment hierarchical condition categories (HCCs) as defined by CMS.

Additionally, our analytic support and risk adjustment expertise interprets risk score trend data to create both a prospective and retrospective risk adjustment strategy.

Manage Error Reconciliation

Optimize encounters and claims data submission throughput with our data transformation and submission tools that support the entire cycle of data submission.

Receive and analyze data for requirements and pre-validation prior to submission.

You can streamline error prioritization, correction, adjustment, resubmission, and status tracking to minimize overall claims data risk.

Increase Member Engagement and HEDIS Scores

Enable member engagement with our strategic tools and services that facilitate communication, risk-gap closure, and monitor performance.

Our data-driven, omni-channel messaging educates and assists members with care compliance. These interventions drive members to resolve health gaps and improve outcomes, increasing trust, member retention, and risk-gap closure.

Additionally, quality performance reporting and analytics provide insights that drive performance improvements and HEDIS score increases.

Gain Visibility Into Medical Records

Take advantage of automated workflows, a national network of reviewers, and experienced clinical auditors to ensure complete medical record documentation as part of your risk adjustment strategy.

Access and easily manage a secure, web-based dashboard for your projects, supported by reviewers that must maintain a 95% accuracy rate.