What You Should Know:

• In recent years, the complex payer claims and administration market has seen several changes. Historically, payers have used multiple technology vendors and homegrown tools to meet their broad functionality needs. Now, payers are looking to consolidate platforms to improve efficiency and their ability to manage multiple business lines.
• As finding a platform that meets payers’ complex needs can be challenging, a new report by KLAS provides a comprehensive look at which business lines vendors are focused on, which vendors are gaining or losing market cons.

Key Insights into Payer Claims and Administration Platforms 2023

1. Cognizant & HealthEdge Are Clear Mindshare Leaders; Support & Delivery Challenges Remain for Both: Cognizant is a prominent player in the market, often a top choice in purchasing decisions. Their solutions, such as TriZetto Facets and QNXT, offer comprehensive features used by payers of all sizes. Users generally trust the software’s ability to handle various business aspects. Satisfaction is high, with users noting improved functionality and efficiency over time. Some issues include delayed support and excessive customization, which can reduce efficiency and stability, prompting a few dissatisfied users to seek alternatives. Still, most Cognizant users plan to stick with the vendor. HealthEdge is gaining traction among payers considering solutions. Their advanced technology and modern user interface attract buyers. Current users find the solution enhances operational efficiency, automates adjudication effectively, and excels in benefit configuration and claims processing. Some want better billing functionalities and more engagement from the vendor, including training and timely support. Challenges reported include post-upgrade defects and inadequate project management during implementations.
2. Provider-Sponsored Health Plans Frequently Consider Epic; SS&C Health* Continues to Lose Customers: Epic is a favored choice for provider-sponsored health plans using their EMR in clinical settings, driven by consolidation, integration benefits, and strong existing relationships. However, challenges arise from less experienced health plan implementation teams leading to usability problems. Athenahealth’s solid product quality, EMR integration, and upgrade processes are praised by their customers, though usability improvements are desired, and limited consideration in purchasing decisions is noted due to ownership changes and uncertainty. SS&C Health customers utilize the system for ACO contracts but express dissatisfaction with slow technology development, uncertainty about the roadmap, and replacements being driven by outdated technology and perceived lack of innovation and scalability. KLAS has not recently validated wins for athenahealth and SS&C Health.
3. SKYGEN USA & Viveka Health Seen As Solid for Specialty Plans & Small Plans (Respectively); Mphasis (Eldorado)* Still Falling Short of Customer Expectations: SKYGEN USA’s product is considered user-friendly and versatile, supporting specialty business lines like dental, vision, and Medicaid. While some customers find SKYGEN adaptable and responsive to customization needs, others highlight concerns about lacking proactive bug alerts, training, and customization explanations. A need for enhanced customization and functionality support for specific commercial plans is also expressed. KLAS validated two health plans opting for SKYGEN due to its robust configurations and integration capabilities with clearinghouses and cybersecurity tools. Viveka Health caters mostly to smaller health plans and TPAs, appreciated for its executive engagement, user-friendly approach, and innovative member-facing mobile app. Advantasure* primarily serves Medicare Advantage enrollment, with its recent acquisition by UST HealthProof casting uncertainty on customer satisfaction. The solution is praised for real-time MA eligibility checks but criticized for struggling with multiple business lines and an inefficient workflow due to segregated billing and enrollment functions. Customers demand improved issue resolution timeliness, and some consider leaving due to unsatisfactory vendor relations. Limited data on Mphasis (Eldorado)* suggests disappointment among mostly TPAs, citing platform quality issues and sluggish implementations.
4. Vendors Who Are Considered but Not KLAS Rated: In addition to vendors assessed by KLAS, payers making purchasing decisions also consider other options. enGen (formerly HM Health Solutions) specializes in serving Blues plans and offers BPaaS services. Flume Health has experienced recent growth, engaging with newer payer types like start-ups, nontraditional plans, and self-insured employers. This vendor is seen as technologically innovative, particularly in network management features. Oracle is frequently considered due to its established work with large payers and scalability, although its adoption is more prominent in non-US markets, raising concerns among US payers about its ability to handle US business lines. PLEXIS Healthcare Systems has gained traction due to advanced technology in their newer product version, despite being replaced by two organizations. VBA garners a few considerations, primarily focusing on the TPA market, and is noted for its positive reputation in that space. For information about other non-rated vendors’ claims and administration offerings, consult KLAS’ 2022 vendor guide.

In 2020, the Department of Justice estimated that fraudulent, wasteful, and abusive (FWA) billing practices account for more than $100 billion of the nation’s healthcare expenditures.¹ Today, the National Healthcare Anti-Fraud Association (NHCAA) conservatively estimates that healthcare FWA costs the nation about $68 billion annually, representing 3% of the nation’s $2.26 trillion in healthcare spending.²  FWA estimates from commercial health plans range as high as $230 billion annually, or 10% of total healthcare spending.³ 

This lost money is far from a concept or abstraction. Every dollar lost to fraudulent, wasteful or abusive billing hurts patients, honest providers, payors and governments. Third-party benefits providers often receive outsized blame for these costs, when in reality, fraud, waste, and abuse is extremely difficult to detect using conventional methods because providers submitting excessive or fraudulent billing claims are constantly changing their methods to avoid detection. 

Fortunately, new advances in artificial intelligence (AI) technology provide our industry a clear path forward to lowering healthcare costs by reducing excessive or overbilling in a way that rewards good providers and returns more dollars to patient care. By helping healthcare payors detect and prevent fraudulent, wasteful and abusive billing practices in greater quantities and before payments are made, it is estimated that up to $1 trillion in fraudulent, wasteful, and abusive costs can be eliminated from U.S. healthcare by 2030. It’s time to stop blaming benefits providers for spiraling costs and start addressing the technology that powers their day-to-day healthcare claims editing, audit and review systems. Here are the key concepts to consider. 

Static Claims Editing Systems Are Exploitable

Most healthcare benefit systems are based on a static, rules-based or use case-based technology that audit a very narrow set of criteria in determining whether a healthcare claim should be paid to the provider. While these systems do a good job of processing and paying billions of claims each year, their antiquated technology allows hundreds of billions of dollars in excessive bills or fraudulent bills to be paid. It’s not because the claims management companies don’t want to stop fraudulent and excessive billing, it’s because their technology can’t see the exploitation that’s occurring. 

Technology Has To See Provider Behaviors, Relationships and Outliers 

When cases are reviewed and adjudicated using traditional rules-based, use case-based and conventional AI methods, dynamic provider behaviors, relationships and outliers are hard to detect. You have to see a provider’s behavior around a claim and all claims and that provider’s relationships with other providers in order to detect fraudulent, wasteful and abusive billing at a significant level before claims are paid out. This means that this sophisticated, interdependent relationship between providers, a current claim form, historical claim forms, and all other providers in a network has to be able to be identified, analyzed and reported on in less than one second when a claim is submitted for payment. 

The Promise of Artificial Intelligence 

AI scares a lot of people, because it is hard to wrap your arms around what it is. Simply stated, one definition of artificial intelligence (AI) is technology that thinks and does what a human can do, but much faster. Even this simple description leaves out the benefit of unsupervised AI being able to identify an infinite number of ‘math problems’ that a human might not even know to look for in a data set. 

Early AI, and much of the conventional AI used in healthcare FWA detection and payment integrity work today, is not much more than a really advanced Excel spreadsheet. Much of the conventional AI operates using structured machine learning. This means that a machine is trained to perform an algorithm or series of algorithms that take an “if-then” approach to analyzing data. 

These structured machine-learning approaches are very helpful, but miss a lot of the dynamic trends, patterns and outliers that can be detected by advanced, unsupervised machine learning. To ‘see’ all of the FWA activity, you have to deploy unsupervised machine learning that identifies trends, patterns and outliers without being “told” specifically to go perform the task. This enables payors to see new fraud trends and patterns forming in near real-time that are indicators of behaviors and relationships that may be signs of excessive payments, over-payments, or even fraud. In short, you can see things and stop things from happening that you did not even know to tell your technology or staff to pursue. 

The Reality Of Integr8 AI^™ Technology In Stopping FWA 

Integr8 AI technology is a new generation of artificial intelligence that is patented for the detection of operational threats. The first application of the technology is to enable healthcare payors – commercial health plans, TPAs, CMS programs, etc. – to take a dynamic, provider-centric approach to processing, auditing and paying healthcare claims. This technology has proven to increase FWA detection by 2X to 10X in initial commercial use, all because it can “see” FWA activity that conventional technology can’t see. And Integr8 AI can see it in a way that does not slow down the claims editing, review and payment process. 

As one payment integrity executive said, “We need to be able to see the FWA activity that we all know is there. Current technology just doesn’t let us see the volume of FWA that next-generation Integr8 AI technology enables. The best part is that this type of technology operates on top of our current claims editing system. We don’t have to make new capital investments to make a big difference fast.”  

The Bottom Line for Benefits Providers

The battle against spiraling healthcare costs has important implications for every stakeholder in the healthcare value chain, but third-party benefits providers stand to benefit the most when fraudulent, wasteful and abusive costs are controlled. Today, almost a third of all insured Americans receive their health coverage through a third-party provider. Removing fraudulent, wasteful, and abusive costs helps benefits providers lower the cost of benefits for customers and their employees, automate and streamline operations, and increase bottom-line profitability. Technology, like Integr8 AI, enables the benefits to be quantified quickly and recognized almost immediately – regardless of what claims editing and adjudication system is being used. 

Now is the time for benefits providers to embrace sophisticated AI solutions for claims management, moving from a relatively static, claims-based model to a dynamic, provider-centric model. It’s time to take control in the fight against adaptable, malicious actors. That fight starts and ends with thinking about the technologies we have in place. 

About Theja Birur 
Theja Birur is the founder of 4L Data Intelligence and inventor of the patented Integr8 AI intelligence platform. She has 20 years of experience in analytics and artificial intelligence with most of that focused on solving payment and quality challenges for healthcare payers and public health agencies. Her career includes work in the government sector with the Ontario Ministry of Health in Canada, with IBM as a management consultant, and in the IBM Innovation Lab focused on analytics. Prior to founding 4L Data Intelligence, Theja worked as a consultant for the California State Compensation Insurance Fund where she was an Associate Director over Big Data and Data Warehouse functions.

In 2020, the Dental Care Alliance (DCA) experienced a significant cyberattack on its systems, which lasted approximately an entire month. This gave the threat actor an extended period to compromise the healthcare organization’s servers and extract the private and confidential information of around one million patients. 

This is just another example of how vulnerable the healthcare industry is to cyber criminals looking to exploit security weaknesses. Healthcare organizations are prime targets for threat actors who are fully aware that their targets are invested in keeping their systems and businesses up and running efficiently and securely. This is especially critical in protecting patient privacy and data, particularly when it comes to impacting life-saving information and equipment.

The incident

The cyberattack on the DCA was launched between Sept. 18 and Oct. 11, 2020. During the month of the breach, a cybercriminal was able to access various confidential files, including patient data such as names, contact details, treatments, diagnoses, patient account numbers, their dentist’s names as well as billing details and health insurance data. In 10 percent of the cases, bank account numbers also were compromised, making this the second-largest reported attack that year. 

The attack resulted in a class-action lawsuit, which ended in a $3 million settlement against the DCA. The DCA was accused of negligence for its failure to protect and maintain its systems and infrastructure against breaches, and for failing to implement proper security monitoring. It also was cited for neglecting to upgrade its security measures and to implement proper cybersecurity hardware and software, as well as adequately train its employees. As a result, patients feared an increased risk of fraud. 

While it was not publicized how the attacker gained initial access to the company’s network, plaintiffs argued that it was the DCA’s poor cybersecurity practices that exposed them to the risk of identity theft and fraud. 

Unfortunately, this is not the only case in which an organization has been sued over alleged negligence. Eye Care Leaders was accused of concealing multiple ransomware attacks in 2021, which resulted in a provider-led lawsuit. Not only does this highlight the frequency of attacks on healthcare organizations, but it also underscores the immense cost that is associated with failing to understand risk and provide adequate cybersecurity protocol and measures. Just a single security incident can lead to reputational damage and significant financial losses. This is further exacerbated by the consequences of breaches of confidential patient and client information.

Both cases are windows into the high-stakes cyber risk landscape for healthcare providers and payers, particularly when it comes to an organization’s being fined by the federal government for HIPAA violations. 

Cyber risk in healthcare

In 2021 alone, the healthcare industry was hit with 849 cyber incidents, with 571 of these confirmed that private data had been accessed, according to the Verizon Data Breach Investigations Report. This placed healthcare in eighth place for industries targeted by attacks, and in third place for number of data breaches, out of a total of 21 categories in the Verizon report.

By using past cyber events and parameters such as revenue, number of employees and number of database records, it is possible to estimate a quantified value of risk to which companies are exposed. By using benchmark values, one can deduce that the healthcare industry shows relatively higher rates of reported breaches in comparison to other sectors (though that is in part driven by stronger data privacy policies and required reporting for smaller incidents to meet federal regulations). There is a 9.3 percent overall probability of an annual incident targeting this industry.

The probability of incidents happening in a year and the estimated cost by risk category within healthcare is as follows:

• Insider Error: Probability: 29.95 percent, cost: $73.6 million 
• Insider Misuse: Probability: 24.99 percent, cost: $47.2 million 
• Basic Web Application Attacks: Probability: 9.19 percent, cost: $42.1 million 
• System Intrusion: 4.83 percent, cost: $5.4 million 
• Social Engineering (Phishing, etc.): Probability 3.80 percent, cost: $6.6 million 
• Denial of Service (DoS): 2.19 percent, cost: $7.5 million 
• Ransomware: 3.85 percent, cost: $929.9 thousand

In quantifying the risk, healthcare organizations can better calculate their risk appetite and allocate spending more efficiently to bolster security where needed. This not only will increase overall cybersecurity, it also will reduce wasted spending on protecting infrastructure that isn’t as vulnerable or may not need as strong measures as other areas. 

Bolstering cybersecurity 

In order to prevent falling victim to a cyberattack and avoid being entangled in costly lawsuits, organizations should foster a strong cybersecurity culture and be aware of the risk to which they could be exposed as well as the potential value associated with it. In addition to increasing overall visibility over devices on and connections to the network, expanding cyber threat awareness training for staff and implementing multi-factor authentication, organizations should know their risk. 

What does this mean? Understanding risk can best be done by quantifying its value. By using an international standard, such as FAIR (Factor Analysis of Information Risk™), organizations can estimate their risk financially, which allows them to better implement cybersecurity strategies according to where higher risk exists.  They can allocate budgets and understand their risk appetite more thoroughly as it allows them to see how much different risks could cost the business. 

Ultimately, quantifying risk would allow organizations to understand what’s at stake and to prepare and invest accordingly. 

About Bryan Smith

Bryan Smith is the CTO of RiskLens, which helps organizations make better cybersecurity and technology investment decisions with software solutions that quantify cyber risk in financial terms. Smith is a broad technologist with over 20 years of software engineering experience. His expertise includes building enterprise scale web applications, cybersecurity, and big data. Smith led the development of RiskLens’ enterprise cyber risk quantification and management platform. Prior to RiskLens, Smith helped build the nation’s first digital archives enabling it to scale 3400% over five years.

As the healthcare industry continues to evolve, there is a growing need for innovative solutions that not only improve the quality of care but also make care more accessible. Non-emergency medical transportation (NEMT) plays a crucial role in helping patients get to where care is delivered. As healthcare reform efforts continue to gain momentum, transportation benefits have become an increasingly critical component of providing equitable care to patients. NEMT helps close the health equity gap by ensuring all patients can access care, regardless of their location, medical needs or transportation options.

In recent years, technology has played a significant role in the advancement of the NEMT industry. Modern NEMT solutions streamline the ride booking and scheduling process, introduce new modalities, improve the overall experience for patients, and decrease fraud, waste and abuse (FWA). For decades, the industry lacked a patient-centric approach focused on efficiency, reliability, and accessibility for all populations, especially those enrolled in Medicare Advantage and Medicaid plans.

A reliable NEMT program can help health plans reduce administrative burden, lower the number of missed appointments, and ensure that patients receive the right level of care and support at the right time during their healthcare journey. Using integration services, health plans can integrate NEMT solutions and programs directly into existing platforms to better manage the member experience and provide an extra layer of connection for members when they utilize these benefits.  

By collaborating with innovative NEMT partners, health plans have made great strides to enhance the overall member experience. Historically, the member journey was largely overlooked, limiting members to two-day-plus advanced notice or long wait times for rides. With the introduction of on-demand ride-booking services through rideshare partners like Uber and Lyft, member needs are prioritized and personalized. Patients can book a ride when and where they need it; then, plans receive real-time updates and notifications during a member’s ride and can make any necessary adjustments as needed. Real-time ride monitoring helps reduce stress and anxiety for patients, prevents FWA, and ensures every ride has a digital record complete with geolocation at every step of the journey.  

While technology-first NEMT has advanced rapidly over the past few years, we’ve only begun to scratch the surface of how it can revolutionize care accessibility. As Medicare Advantage and Medicaid plans continue to grow, NEMT partners will play an increasingly important role in scaling transportation benefits. By working with healthcare providers and payers to integrate NEMT benefits into existing programs and systems, we can provide high-quality transportation services to our most vulnerable populations.

Given the proximity to high-acuity and underserved patients, who are commonly enrolled in Medicare Advantage and Medicaid plans, it’s important to determine whether a transportation provider has the capacity and expertise to meet the individual needs of each member. In a recent study, 21% of U.S. adults without access to a vehicle or public transportation skipped needed medical care last year. This experience is shown to vary depending on other factors such as race and ethnicity, household income, urban or rural location, disability status, and more. Expanding ride modalities with options like on-demand rides provides members the flexibility and comfort they’re looking for in an increasingly-consumer driven healthcare environment as well as plans with the tools they need to close these health equity gaps in accessing care for a diverse population. 

By offering members benefits that work for them and their unique needs, plans can focus on increasing benefit utilization and improving critical present and future Stars Ratings benchmarks like member experience and health equity. When measuring a program’s effectiveness, vendors and plans must work together to decide which data to capture, determine what’s working, and identify areas for improvement. Technology-first NEMT plays a critical role in capturing data and turning it into metrics that matter. 

Despite great strides made to help address the social determinants of health (SDoH), such as transportation access, government regulations continue to play a critical role in shaping the industry’s growth and impact. Various regulations, such as the Medicaid Non-Emergency Medical Transportation Benefit and the Americans with Disabilities Act, have positively impacted how patients access care and the quality of transportation services provided by NEMT vendors. These regulations are crucial for individuals who may not have reliable transportation options, especially those living in rural or low-income areas, and help ensure NEMT providers meet specific quality standards and are held accountable for providing safe and dependable transportation services. As the NEMT industry continues to evolve, it is important for providers to stay informed about the latest regulations and to work closely with government agencies to ensure they are providing the highest quality transportation services possible. By doing so, they can help close the healthcare equity gap and ensure all patients have access to the care they need.

While we can’t predict all the roadblocks the healthcare industry will face in the future, it’s clear that a more efficient, reliable and cost-effective NEMT solution will continue to drive better outcomes for health plans and patients. 

About Andy Auerbach

Andy Auerbach is the Chief Revenue Officer of SafeRide Health, the leading technology-first platform connecting patients to care one ride at a time.

Contract Logix white paper reveals the top 10 most important contract management KPIs and how to maximize their impact

It’s critical for every healthcare organization to monitor and optimize its contracts and contracting processes using key performance indicators (KPIs). But how do you determine which KPIs are the most important to your business and how do you harness the data required to benchmark and track them?

By benchmarking and tracking these KPIs in your healthcare organization, you will greatly improve the performance of your contracts and contract lifecycle management processes with patients, providers, payers, and more.

A new white paper from Contract Logix outlines:

• 10 common KPIs used by healthcare contract management professionals
• How utilizing KPIs can decrease the overall time to an executed contract
• Why KPIs can uncover trends and opportunities to reduce expenses

John Erwin, CEO of Carenet Health

I was pleased with the robust turnout at HIMSS this year; it does seem like the healthcare industry is making up for the lost time from the pandemic. The topics that dominated the conference included teasing out the nuanced approach to safely deploying Chat GPT/AI into the industry (and when not to), health equity, and the patient journey. Workforce burnout continues to be a major issue in healthcare, though I think we could have spent even more time discussing solutions here, given its profound impact on every aspect and stakeholder of the care continuum. While this is not a new phenomenon, it is certainly the biggest challenge to the industry currently. Current policies will have to evolve to ensure job stability and staffing for healthcare, which is where the innovative use of AI and technology can bridge the gaps. 

Adam Mariano, President & General Manager of Healthcare, LexisNexis Risk Solutions:

The big opportunity at HIMSS this year is that everyone is finally talking about social determinants of health, bias in care and health disparities in a way that is not just theoretical but is actually ‘let’s take action’. I’m really pleased to see lots of our partners, competitors,  providers, payers, life science folks really engaged and willing to participate in these types of conversations this year.

Kimberly O’Loughlin, CEO of HRS

HIMSS is always an energizing event. It’s a wonderful venue to connect with customers, be inspired by what others are doing, and share stories and ideas for innovation. It was especially meaningful to have our customers present the wonderful results they are achieving by leveraging our remote patient monitoring and care platform. 

Solutions providers who can provide turn-key capabilities and wrap-around services and be true partners with clients are what is needed. The only way we are going to enable real performance improvements and address critical issues like clinician shortages and burnout is if we simplify and streamline workflows for clinicians. Artificial intelligence/machine learning and the power of what it can do was another key topic of discussion at HIMSS. We are excited about what it can bring to remote care delivery to drive patient engagement, improved outcomes, and clinical workflow efficiencies to even higher levels.

BJ Schaknowski, CEO at symplr

The potential to save on streamlined architecture was a significant theme at HIMSS this year. Many agreed that hospitals are only taking advantage of a small percentage of the multi-million-dollar systems available to them. And as financial pressures increase, healthcare leaders are implementing more deliberate decision-making to better leverage vendor partnerships and optimize software purchases. Spending is focused on enterprise-wide solutions as opposed to best-in-breed and price sensitivity is a major factor in software purchasing. 

Nicole Rogas, President at symplr

Health equity was a cornerstone of conversation this year at HIMSS, and rightfully so. Together, as healthcare vendors and providers, we need to come together to provide a solution. Every person should have access to care, regardless of race, ethnicity, age, socio-economic status, etc. Organizations emphasized the potential for digital health to bridge the health equity gap by increasing access for patients and eliminating barriers to care. In support of health equity initiatives, interoperability remains top of mind for industry leaders. When health equity is a key objective in data strategies amongst providers and vendors we can develop and deliver solutions that pave the way toward more equitable care, improving health outcomes, and reducing health disparities.   

What You Should Know:

• Strategies employed by payers, provider-sponsored health plans, and provider organizations are starting to become more proactive, and the need for solutions with prospective, predictive capabilities is rising. Additionally, amid rising healthcare costs and economic uncertainty, organizations are looking for solutions that deliver more for less.
• A new KLAS report examines risk adjustment vendors’ abilities to drive outcomes and value, their prospective capabilities, and their offerings’ ease of use.

Key Insights From Risk Adjustment 2023

Each year, KLAS interviews thousands of healthcare professionals about the IT solutions and services their organizations use. For this report, interviews were conducted over the last 12 months using KLAS’ standard quantitative evaluation for healthcare software, which is composed of 16 numeric ratings questions and 4 yes/no questions, all weighted equally. Combined, the ratings for these questions make up the overall performance score, which is measured on a 100-point scale. The questions are organized into six customer experience pillars—culture, loyalty, operations, product, relationship, and value.

Key insights are as follows:

1. Episource & Veradigm Offer Broad Capabilities & Positive Customer Experience: Organizations using Episource and Veradigm highlight the vendors’ breadth of capabilities and are often more satisfied than customers of other broad vendors in the market. Episource exceeds customers’ expectations for chart retrieval rates and coding accuracy by partnering with them on how to use the comprehensive solution. Respondents appreciate the direction the vendor is moving in, stating that they have become more proactive and the project managers have improved. The few very frustrated customers note they were oversold on health assessments, which the vendor has since discontinued. Validated Veradigm customers report a stronger partnership post-acquisition thanks to executive leadership changes as well as the vendor’s willingness to fix problems, develop the solution, meet regularly, and provide account managers who help organizations meet goals. The solution is seen as flexible and helps customers target which patients should meet with a physician; analytics for gap closure is also a strength. A couple of respondents feel the coding services need improvement, and there are mixed reviews about the implementation and training.
2. Well-Known Vendors Inovalon, Cotiviti & Optum (Limited Data) Falling Behind: Inovalon is used more broadly than other risk adjustment vendors and is often used for their payer quality solution. The 33% of respondents who would buy the solution again say training during implementation and an internal QA process are critical to achieving outcomes (e.g., cost savings, useful analytics, good retrieval rates). Over half of all respondents plan to leave, and others would not buy the solution again due to the cost, missing outcomes, staff frustrations, and lack of promised technology. Customer feedback is mixed for Cotiviti (who is also well known for their payer quality solution). The most-satisfied customers feel the solution (while expensive) drives value, the chart retrieval helps them get needed information, and the support is helpful. Frustrated customers cite a poor, reactive vendor relationship and old technology. Customers of Change Healthcare (recently acquired by Optum) share that the reporting works well and that they value having standing meetings with the vendor. Most respondents report challenges; 29% plan to leave as a result of lacking advancements and usability, inaccurate data, and unhelpful support. Of the four interviewed Optum (limited data) customers, only one says the vendor is part of their long-term plans. Those who are leaving mention inconsistencies, problems with lagging, an outdated UI, and buggy upgrades. A couple of respondents highlight that their account manager is great to work with but note issues getting problems solved.
3. Health Assessments from Vatica Health Offer Unique Approach that Drives Value for Customers: While also supporting customers’ strategies in many risk adjustment areas, 2023 Best in KLAS winner Vatica Health takes a unique, provider-centric approach to risk adjustment by providing point-of-care health assessments. This approach drives value for customers of all types, who note the solution can provide accurate HCC codes, significant provider penetration at the point of care, real-time prospective data, decreased care gaps, and predictions for future conditions. Physician users specifically note that the tool fits well into their workflow; a few respondents mention challenges related to initial physician buy-in. Matrix Medical Network (limited data) is used by a large customer base for in-home health assessments, and customers report the vendor provides a good experience at a fair price. Some respondents say that the nurses are excellent and bring insights that shape members’ care. Customers feel the vendor is less flexible than desired after removing some of their offerings (such as the mobile health clinic services), leaving customers to feel stuck following the status quo.
4. NLP from Apixio Leads to High Accuracy, Narrow Focus Has Some Customers Looking Elsewhere; Health Fidelity & Talix Customers Experiencing Bumps Post-Acquisition: For chart reviews and coding services, AI/NLP capabilities are often important, and Apixio, Health Fidelity, and Talix provide these capabilities to enable organizations to identify risk-gap opportunities effectively and accurately. Apixio’s AI-powered solution helps customers retrospectively look at charts to properly document and find a higher rate of overlooked codes. Most users are satisfied with their outcomes; the 35% who are considering leaving are looking to consolidate and find a solution with broader, more prospective capabilities (which Apixio has begun to introduce over the last year). Health Fidelity by Edifecs offers a broad set of validated capabilities, and satisfied customers appreciate the solution’s ability to find missing HCC codes via NLP. Many respondents have seen an ROI, especially from the post-encounter functionality; some report false-positive issues with this functionality. The majority of customers feel uncertain about the future post-acquisition due to declining proactivity, service, and delivery of promises (especially related to the product working as promoted). Talix by Edifecs provides a focused solution that utilizes NLP to improve the accuracy of chart reviews and coding services, and customers often describe the solution as easy to use. Respondents initially reported post-acquisition service challenges due to turnover; however, some have more recently seen an increase in support and responsiveness.
5. Advantmed Sees Increased Customer Satisfaction after Leadership Changes; Ciox Health Often Used for Chart Retrieval but with Some Missed Expectations: Customers report Advantmed has improved their partnership by becoming more flexible, proactive, and responsive when problems arise, especially since recent leadership changes were made. Respondents mention that the good integration drives successful retrieval rates and that the vendor delivers what is expected. Reporting is the most common problem among respondents because of data quality issues and struggles finding previous reports. Ciox Health customers often work with the vendor due to relationships with provider organizations that also use Ciox Health. Several respondents have seen improvements in the account managers’ ability to solve problems and keep promises, and a few note that using one vendor for both coding and chart retrieval has increased their outcomes. Reported frustrations include fewer chart retrievals than expected and nickel-and- diming during the reporting and retrieval process.
6. For Analytics, EXL’s Easy-to-Use Offering Aids Customer Utilization; MedInsight & Pareto Intelligence Offer Prospective Capabilities, though Broad Offering Can Add to Complexity: EXL’s easy-to-use, intuitive solution and strong analytics help customers better capture codes, improve care gaps, and predict future progress. Respondents also highlight that the vendor is willing to provide additional training as needed. Going forward, customers want EXL to expand their offering and deliver more AI/predictive capabilities. MedInsight offers a risk and payer quality analytics platform that provides prospective and retrospective views, enabling users to better benchmark, find care gaps, and identify risk. Customers praise the customizability and helpful support. Due to the platform’s complexity, a few customers feel the solution could be easier to use and want more guidance. Additionally, provider customers (who tend to be the most frustrated) often mention the need for better EMR integration. Pareto Intelligence provides analytics- focused services and technology with predictive algorithms that assess risk. Interviewed customers say the solution drives outcomes and appreciate the vendor’s partnership, flexibility, and responsiveness. Many respondents note the product can be difficult to use, and a few report recent support bumps from staff turnover. Arcadia customers (mostly provider organizations) say the solution drives outcomes for population health and reduced care gaps. The solution’s complexity lessens the ease of use for customers, who note utilization training could be helpful. While the vendor is solving problems, some respondents feel resolution times are longer than expected; implementations and integration are also cited as frustrations.

What You Should Know:

• 1upHealth, a modern data platform that’s cloud-based, API-enabled, and FHIR-native today announced the close of a $40M Series C investment led by Sixth Street Growth with participation from existing investors F-Prime Capital, Jackson Square Ventures, and Eniac Ventures. 
• Founded in 2017, 1upHealth’s FHIR®-native platform designed for interoperability and modern computing is used by over 75 enterprise organizations including leading national and regional health plans, the highest performing CMS ACOs, international clinical research organizations, and over 20 state Medicaid agencies. By leveraging the industry’s FHIR standard, modern and open cloud architecture, and restful APIs, 1upHealth helps customers acquire, store, and interact with the data needed to power their business operations and analytics.  

Expansion Plans

1upHeath plans to use the latest round of funding to accelerate efforts in building the 1upHeath Data Cloud across three key areas:

1. Invest in product development and engineering in preparedness for proposed and future CMS regulations
2. Enhance 1upHealth data cloud infrastructure for serverless scalability and open access
3. Grow Customer and Services teams to support market expansion across payers, providers, pharma, digital health and more

What You Should Know:

– MedArrive, a Mobile-integrated care management platform company today announced $8M in new funding led by Cobalt Ventures, a wholly owned subsidiary of Blue Cross and Blue Shield of Kansas City (Blue KC). The investment follows MedArrive’s $25 million series A round in November 2021 and brings the company’s total funding to $40.5M to date

– MedArrive plans to use the new investment to expand its payer relationships, build out its team and platform, and scale its business into new markets.

White-Labeled Care Management

MedArrive supports both adult and pediatric populations, providing a white-labeled care management solution that powers care into the home – often for the hardest-to-reach, disengaged and most-vulnerable populations. It connects providers and payers with MedArrive’s field provider network of highly trained and skilled paramedics, EMTs and other healthcare professionals. These field providers visit the homes of patients or members on behalf of their provider or health plan, providing a mix of in-home healthcare services, diagnostics, health assessments, post-acute care and other preventive health measures – while also addressing social care needs like transportation, mobility or nutrition assistance.

When higher-acuity care is needed, field providers will connect people with physician-led telehealth services. The MedArrive platform also includes integrations with a growing ecosystem of specialized partners, which allows field providers to bring even more care services into the home such as virtual behavioral health, retinal screening and maternity care.

“Everyone in America has a right to inclusive, high-quality care, yet too many are left out and have no one on their side who can connect them to the system. That’s what the MedArrive platform and our field providers offer – a trusted and compassionate bridge into the homes of the people who need care the most and at the right time,” said MedArrive CEO and Co-founder Dan Trigub. “The work we are doing with dedicated healthcare organizations, who are committed to health equity, is what drives our team every day, and we are honored to receive this strategic investment from Cobalt Ventures.”

What You Should Know:

– Availity today announced a definitive agreement to acquire the utilization management solution and business unit from healthcare automation company Olive AI, Inc. Financial details of the acquisition were not disclosed.  

– The acquisition of Olive AI’s utilization management solution offers numerous benefits for Availity’s national network of payers and providers. These include lower administrative and medical costs, improved patient access and experience, clinical data for making enhanced strategic decisions, as well as an automated authorizations process between health plans and providers.  

What You Should Know:

– Cognizant expands partnership with Microsoft to give healthcare payers and providers easy access to cutting-edge technology solutions, streamlined claims management, and improved interoperability to optimize business operations and deliver better patient and member experiences.

– As part of the expansion, Cognizant and Microsoft will work together to build an integration roadmap between Cognizant’s TriZetto healthcare products with Microsoft Cloud for Healthcare.

– The companies will also collaborate to develop and run Cognizant’s current and future healthcare SaaS solutions on Microsoft Azure, migrate new and existing clients from on premises environments to streamlined functions managed on the Microsoft Cloud, and support future technologies designed to deliver new insights for payers, providers, and consumers.

Despite holding the promise of delivering superior patient outcomes while lowering healthcare costs, many providers remain reluctant to embrace value-based care (VBC) reimbursement models. Progress toward VBC adoption hasn’t achieved its potential yet, hovering around 60% of all payment models from 2018 to 2021, with the remaining 40% comprised of traditional fee for service (FFS).

Though some providers simply are hesitant to abandon the FFS model that has served them well, others are leery of the technological and management challenges they associate with VBC models. According to consulting firm RTI Health Advance, these include:

• Administrative complexity within the value-based payment ecosystem
• Transitioning upside risk-only to fully accountable care; many providers are challenged to operationalize programs and afford the necessary time and finances
• Value-based models must incorporate and address specialty care as part of the continuum of covered services
• Health equity plans now are required as part of new value-based contracts with the Centers for Medicare and Medicaid Services (CMS) 

The CMS Innovation Center set a goal for all Original Medicare beneficiaries and most Medicaid beneficiaries to be in VBC relationships by 2030. These risk-based care models are designed to encourage proactive care, better population health and reduced spending across the healthcare spectrum. To meet that deadline, provider organizations will need technology tools for administering relationships within a value-based network. 

How Value-based Administration works

VBC networks are comprised of multiple stakeholders that may include hospitals, health systems, private practices, payers, accountable care organizations (ACOs), clinically integrated networks, social service networks and community-based organizations (CBOs). Successful implementation of value-based programs, therefore, requires complex hierarchy support for onboarding, data capture, data digitization, payments, and data exchange. These technologies must support social determinants of health (SDoH) and facilitate value-based payments, quality reporting and other use cases. 

Within VBC networks are many-to-many relationships in which an entity in one network may be engaged in several networks under various contractual engagements with other entities. Such a “network of networks” can work only with an infrastructure that supports the hierarchies between these entities. The architectural framework and processes used to run VBC networks collectively are referred to as value-based administration (VBA).

Figure 1 shows how VBA helps stakeholders across the healthcare continuum – providers, payers, patients, and CBOs – eliminate barriers to participating in a VBC network while also delivering measurable clinical and operational benefits.

Inadequate digital infrastructures

Most healthcare organizations, however, lack the digital infrastructure necessary for VBA. “We can’t graft a new digital, platform-based healthcare system onto healthcare infrastructure designed to support traditional operations and care models,” Mayo Clinic President and CEO Gianrico Farrugia writes in an article for the World Economic Forum. “Healthcare needs transformation. And to truly transform healthcare, we must simultaneously build physical and digital frameworks to meet the evolving needs of patients worldwide.”

Fortunately, healthcare organizations can implement VBA without embarking on a costly rip-and-replace strategy. This can be done through a platform infrastructure that can be deployed as a DaaS (Data-as-a-Service) or as PaaS (Platform-as-a-Service) or the traditional SaaS (Software-as-a-Service) model.  Such an infrastructure allows partner firms and/or clients to use existing applications served up via microservices or extend/create microservices and business applications for their own needs.  

What’s needed to enable VBA 

To fully leverage relationships in a VBC network, providers must: 

1. Implement a robust cloud-based data infrastructure to allow real-time clinical decision-making, information sharing and analytics
2. Realign downstream reimbursement to include both medical and non-medical providers (behavioral health services, drug treatment centers, etc.)
3. Incorporate SDoH resources and partners, such as CBOs
4. Have a dashboard view into real-time performance against all contracts 

An integral part of effective VBA infrastructure is ML (Machine Learning) and Artificial Intelligence (AI) technologies.  A key to implementing digital transformation is data digitization and amalgamation of that data with structured and external data sets so that a 360-degree view of the patient can be achieved to provide actionable insights to Payers, Providers and Patients.  AI technologies, coupled with ML algorithms in a robust data engineering framework that enables to-and-from integration between systems with this digitized data, are needed to make this a reality.  These facilitate better automation of tasks and decision-making processes since data-driven insights require digitized data in order to automate processes. A set of secure and scalable cloud-based microservices – on which different applications and integrations are built – then helps facilitate data interoperability as well as opportunities to build/partner/deploy different workflow-based applications for the end users. 

Final thoughts

Though structural and technological barriers impeding VBC adoption persist, many large healthcare organizations are working with technology partners to improve patient outcomes and reduce healthcare costs. Implementing VBA to manage VBC initiatives will empower healthcare organizations to deliver on the full promise of patient-centered, value-based healthcare.

About Rahul Sharma

Rahul Sharma is the CEO of HSBlox, which enables SDOH risk-stratification, care coordination and permissioned data sharing through its digital health platform.

About Lynn Carroll

Lynn Carroll is the chief operating officer of HSBlox, which assists healthcare stakeholders at the intersection of value-based care and precision health with a secure, information-rich approach to event-based, patient-centric digital healthcare processes – empowering whole health in traditional care settings, the home and in the community.  

What You Should Know:

• Uber Health, Uber’s healthcare arm, today announced same-day prescription delivery on its HIPAA-supported, centralized platform.
• For the first time, those using Uber Health—including healthcare providers and health plans—will be able to manage prescription delivery from any pharmacy in their service area through the same platform they already use to coordinate transportation for patients. This launch enables providers to offer a full suite of care solutions that extend beyond the four walls of a clinic and is designed to improve patient experiences and health outcomes.

Enabling Health Systems to Give Patients Seamless and Direct Access to Prescriptions

Today’s news furthers Uber Health’s mission to optimize how patients access care. The platform allows connectivity to the key services providers require to address patient needs including prescription delivery, stress-free rides, and soon, the delivery of healthy food and over-the-counter medicine for those who need it most—including Medicare Advantage and Medicaid beneficiaries.

When Uber Health launched in 2018, the business focused primarily on streamlining non-emergency medical transportation (NEMT) options, enabling patient populations—especially underserved and vulnerable communities—to get to and from medical appointments. While transportation is an important social determinant of health, it’s only one piece of the patient care puzzle. For example, a patient discharged from a hospital regularly requires a ride home and to follow-up appointments, as well as new prescriptions. Launching prescription delivery powered by ScriptDrop on the Uber Health platform ensures organizations can fulfill their duty of care obligations to patients by arranging direct, same-day delivery of their prescriptions while tracking when they arrive, enabling them to fully “close the loop.”

The tracking of care delivery across multiple disciplines promises a paradigm shift in an industry where providers and health plans could lose sight of patients outside of a provider’s office. Imagine a patient with a chronic kidney disease diagnosis who regularly needs transportation to specialist appointments that result in prescription changes of critical medications. Rather than burdening the patient with homework, Uber Health furthers the patient care team’s ability to arrange these services directly and track that they occurred. Uber Health facilitates critical touchpoints that enable payers and providers to provide maximum quality care at minimum cost.

“At Uber Health, we are building solutions that address lessons we’ve learned from years at healthcare companies operating in value-based care contracts. Too much time has been spent ensuring patients had a ride to their follow-up appointment, had picked up the right prescriptions, or had access to food,” said Caitlin Donovan, Global Head of Uber Health. “That’s why I’m proud to add a scalable prescription delivery solution to our platform that empowers care teams to fully close the loop. From prescription delivery and NEMT today to healthy food and grocery delivery in the coming months, Uber Health remains committed to delivering a more connected care journey through a single, seamless platform.”Powered by an integration with ScriptDrop, prescription deliveries can be facilitated through any pharmacy registered with the NCPDP within delivery coverage areas. Importantly, Uber Health allows for access to delivery coverage areas that include pharmacies dispensing medications covered by the 340B program, helping health plans and providers reach low-income and uninsured patients.

Clinical Natural Language Understanding (cNLU), the technology by which computers extract meaning from clinical text, is quickly becoming a common feature in the healthcare IT landscape. In 2021, 30% of surveyed healthcare organizations were either using or exploring the technology.  (Gradient Flow, 2021). Similar adoption is occurring in the UK as well. (Wu et. al, Nature, 2022). Today, cNLU is being applied to billing/coding, trial enrollment, registry creation, clinical decision support, prior authorization, fraud/abuse detections, and other labor-intensive workflows. In this blog we focus on the cNLU task of extracting and coding concepts from clinical notes, thereby converting unstructured data – the state of the vast majority of clinical data in electronic medical records (EMRs) – into structured data. This list will expand over time, as more clinical innovators become familiar with the technology, and the cNLU tools become better, cheaper, and more accessible. However, for many uses, there is one thing holding the technology back-it generates too much information and, relatedly, too much noise.

First, we should celebrate that we are now at a point where advances in machine learning are enabling sufficiently performant models that understand the meaning of the text in a manner that approximates professional reviewers. The task of concept extraction and coding is typically evaluated by metrics. For example, for every instance of depression in a corpus of clinical documents, how many instances were correctly captured by the model? For every instance, the model captured a span of text and labeled it depression, how frequently were those actually cases of depression? But extracting even a seemingly simple concept like “depression” is challenging. A reference to depression might be “patient exhibited signs of significant depressive disorder.” It could also be “patient’s blood pressure was depressed.” A model that differentiates between these cases, and that determines only the former case represents clinical depression, is understanding the nuance of language. 

The problem is still more challenging insofar as references to the medical condition of depression can also occur, and in fact largely do occur, in the context of family histories, as a condition a patient does not/hypothetically could/possibly does suffer from, or as part of a screening. Consider the examples “reports father suffered from significant depression,”  “patient may suffer from depression,” and “chronic disruptions to sleep patterns may result in depression.” In all of these cases, depression is not conclusively present for the patient. As challenging as these cases are, and while not yet as reliable as clinicians, cNLU has already outperformed trained reviewers in extracting insights from charts, including even in high-risk / high-acuity clinics (Suh et. al., Anest & Analgesia, 2022).

A model that reliably extracts and contextualizes all the salient concepts in a corpus of clinical documents and stops there improves the status quo.  However, it does not meet the needs of a user that is inevitably interested in finding very specific pieces of information about a patient, or patient panel. For example, someone who is trying to find evidence of patients who likely have type 2 diabetes but does not have it on their problem lists will want to know which patients have abnormal fasting glucose or hemoglobin A1C results. But a patient’s chart will feature references to thousands of problems, tests, and treatments and might feature a single reference to blood sugar tests, or else a range of results for these tests that generally wouldn’t indicate a need for review. A recent analysis we conducted found that on average a medical chart generates roughly 12,500 data elements. Finding an abnormal result for a specific test is a needle in a haystack problem for someone manually reviewing a chart. But for the vast majority of people who don’t write code to work with data, it’s the same problem for someone working with structured data from the chart. 

For software to meet the needs of someone who reviews clinical charts, data needs to be searchable. This is the case even if organizations run limited purpose models that narrowly find references to a single topic such as diabetes, though we believe users will always have additional questions about their data.  Before a user ever makes a search, all of the instances of hemoglobin A1C – as a1c, HbA1c, hgba1c, et al. – need to be coded the same way, so that when the user searches for hemoglobin A1C, they return the results for any occurrence of that test. Lab values should also be extracted from the notes and associated with tests. Users might want to see any instance of a hemoglobin A1C test for an individual patient or a cohort of patients. They might want to see any instance of the test where the test value is >= 6.5%. They might add a further complication, looking for the same results as above, but – assuming the findings from clinical notes have been aggregated with the patient’s already structured data – filtering out the patients who already have type 2 diabetes on their problem lists. And they might add a date parameter, so as only to return results a reviewer would not already have seen. 

Whether one condition or many, search is the tool that enables a user to find the information they care about. In our view, the blend of the capability to make data searchable, in combination with the clinician’s validation results, is how to maximize cNLU for chart review.

Leveraging cNLU to rapidly structure clinical notes and make the entire medical record searchable holds the potential to free up massive labor pools for more valued tasks. Users of cNLU for chart review already report significant reductions in the time spent reviewing charts for coding improvement, visit preparation, prior authorization review, and chart audit. Rather than relying exclusively on high-cost, hard-to-hire, potentially burnt-out clinical labor to read charts manually, cNLU, by making charts searchable, frees up more of the clinician’s time. To validate results, attend to the most difficult cases, and become more informed about their patients. 

About Kevin Agatstein

Kevin Agatstein is the founder and CEO of KAID Health, an AI-powered healthcare data analysis and provider engagement platform. Prior to KAID, Kevin founded Agate Consulting and held roles at McKinsey & Company and Arthur Andersen where he advised providers, payers, healthcare IT companies, life-sciences organizations, and healthcare venture-capital and private-equity firms. Kevin also led operations for CareKEY, Inc., from its early years through its acquisition by The TriZetto Group.

About Dimitr Lindei
Dimitri Linde is a Clinical AI Specialist at KAID Health, focused on clinical natural language processing. He developed KAID Health’s pipeline to extract and encode information from clinical notes.

What You Should Know:

– Abbott today released the latest installment in the company’s multi-year Beyond Intervention series of global healthcare market research designed to uncover challenges that arise within the patient journey of people living with cardiovascular disease and to identify opportunities for patient care improvement.

– The latest report stems from a survey of more than 2,000 patients, physicians and healthcare leaders, and reveals challenges resulting from a systemic lack of adoption of consumer technologies by healthcare providers, a lack of post-surgical therapy compliance, and consumer dissatisfaction beyond intervention.

Improving Post-Operative Outcomes and Patient Satisfaction

Findings from Beyond Intervention identify key opportunities physicians, healthcare leaders and health technology companies may consider to improve the patient care journey. These include providing a comprehensive care experience to increase patient satisfaction, reducing barriers to post-intervention care, driving better experiences and outcomes, and involving patients in shared decision-making. The report underscores the differences in how patients, physicians and healthcare leaders perceive the effectiveness of technology in the care delivery system.

“Increased penetration of smart devices, wearables and remote self-monitoring tools not only provide granular data on recovery, progress and adherence but critically drive patient engagement and therefore behavioral change,” said Nick West M.D., chief medical officer and divisional vice president of medical affairs at Abbott’s vascular business. “MedTech’s role is to find synergies between how patients and physicians prefer to access information to facilitate positive experiences and outcomes for all patients.”

In its third year, the Beyond Intervention initiative provides continued insight into the state of global cardiovascular care through primary research surveying the perspectives of approximately 2,000 patients, physicians and healthcare leaders. The research provides further insight into the patient journey post-procedural/post-discharge and explores the attitudes and appetites to adopt technology to better help patients recover from vascular interventions.

Key insights from the research include:

1. Patients, physicians and healthcare leaders agree that establishing multiple touchpoints help patients navigate their post-procedure care journey. Most patients surveyed (90%) believe that the two most important factors in navigating their care journey are having a clear understanding of the next steps in managing their disease and having all of their questions answered.

2. There are significant gaps between how patients and physicians view the importance of digital health tools. Patients consider access to an online patient portal and use of digital health tools more important to their overall experience (65% and 62%, respectively) than physicians feel they are for their patients (38% and 35%, respectively). Further, while patients indicated a need for improvement in these tools, physicians and healthcare leaders found the use of these tools as already satisfactory, indicating perception gaps.

3. Patients are facing many barriers to managing their condition and experiencing optimal care post-intervention. Nearly half of the patients surveyed reported finding motivation and time to manage their condition was challenging. A similar proportion described ongoing costs related to treatment as a difficult task. Lack of education and awareness of the progressive nature of cardiovascular diseases is a significant barrier to post-procedural care and adherence.

4. Many patients see technology’s value for managing their own health and wellness. Nearly 60% of patients and half of all healthcare leaders would trust artificial intelligence (AI) to help diagnose or recommend the best treatment; however, just over one-third of physicians agree (34-35%). Yet, 48% of physicians believe big data will help them provide better care in the future.

“Those who work at the intersection of healthcare and technology must straddle the digital divide and work toward greater use of technology in care,” said Jennifer McCaney, Ph.D., executive director at UCLA Biodesign. “We cannot assume that every person or patient has the access to or the means to interact with health systems or care teams in the same way. Stakeholders across the care journey from product manufacturers to payers and providers alike need to empower patients with accessible technologies that better the patient experience.”