You focus on partnering with your providers and members

We’ll help you secure market growth and manage revenue streams across lines of business

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Revenue Growth

Edifecs Revenue Growth enables health plans to optimize their revenue streams. By combining the capabilities of Edifecs Enrollment and Revenue Integrity solutions, we empower plans to consolidate and automate operations across lines of business. Plans can manage enrollment, encounter management and risk adjustment for both commercial and government programs.

A New Approach

To holistically manage revenue streams, the first step health plans must take is to connect their enrollment processes to their encounter management and risk adjustment operations. Across lines of business, Edifecs creates this alignment to mitigate revenue loss in managed Medicaid, Medicare Advantage, the ACA Marketplace and Duals programs in conjunction with standard individual and group products.
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Who We Help


Health Plans

Edifecs ensures health plan revenue integrity by consolidating and automating enrollment, encounter management and risk adjustment operations. We protect plan revenue streams and drive competitive differentiation through scalable solutions for both commercial and government programs.


Pharmacy Benefit Management (PBMs) Companies

We enable PBMs to decrease encounter submission cost and complexity. Through Edifecs, PBMs can reduce IT burden, mitigate health plan abrasion and ensure competitive differentiation in a highly competitive market.

Solution Overview

Health plans can streamline enrollment channel operations and ensure revenue integrity, even across new and evolving lines of business with Edifecs Revenue Growth. Plans involved in individual, group, Marketplace, managed Medicaid, Medicare Advantage and Dual Eligible programs reap the IT, administrative and financial benefits of system consolidation, automation, risk visibility, and integrated exception management workflows.
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Solution Spotlight

  • Encounter Management

    Accurate, complete and timely encounter submissions are vital to accurate risk-adjusted payments and regulatory compliance in government and commercial programs. Pharmacy benefit management companies (PBMs) must reduce health plan abrasion and drive competitive differentiation. Learn how to proactively navigate these challenges, streamline program complexity and reduce costs even in the face of change.

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  • Enrollment Management

    Edifecs Enrollment Management standardizes and validates enrollment intake across channels. Configurable business rules trigger system-driven updates to downstream systems of record. Now users can modernize enrollment channels while standardizing intake—without costly changes to core systems. This is a speed-to-market advantage for your new products and services.

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  • Health Insurance Exchange

    The Edifecs Health Insurance Exchange solution delivers seamless connectivity with a wide range of state, federal Marketplaces and thrd-party systems, enabling health plans to launch and operate in multiple envirnments. Health plans can maintain integration, stay up-to-date with changing mandates and industry data exchange standards and enhance scalability without the complexity and cost of point-to-point system integrations

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  • Risk Adjustment

    Edifecs Risk Adjustment drives powerful, precise, real-time risk score analytics at both the population and member level. Enable effective interventions while closing coding and care gaps. Integrated with Edifecs Encounter Management for comprehensive risk-adjusted program management. Establish robust internal audit programs and prepare for external audits.

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Capabilities

Encounter Management

Accurate, complete and timely encounter and Edge Server submissions are vital to accurate risk-adjusted payments and regulatory compliance in government and commercial programs.

  • Consolidates encounter lifecycle operations across lines of business for both health plans and pharmacy benefit management companies (PBMs)
  • Employs integrated exception management workflows
  • Streamlines the RAPS to EDPS submission and reconciliation process
  • Leverages pre-packaged sets of formats and business rules for state-specific managed Medicaid programs

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Health Insurance Exchange

For health plans, growing and enhancing their Marketplace and private exchange lines of business require seamless, secure connectivity.

  • Provides a flexible business rule engine
  • Delivers automated enrollment exception management workflows
  • Drives binder and premium payment reconciliation
  • Enhances complete enrollment lifecycle dashboard visibility

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Risk Adjustment

Accurate health plan revenue for Marketplace, managed Medicaid, Medicare Advantage and Dual Eligible programs rely on accurate and insightful risk adjustment analytics.

  • Closes gaps in provider coding
  • Enables retrospective and prospective HCC suspecting
  • Enhances local risk scores based on most current view of accepted encounters
  • Promotes dynamic intervention planning

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Enrollment Management

New and expanding enrollment channels for health plans require standardized and integrated intake capabilities across lines of business.

  • Facilitates enrollment file failure identification and resolution
  • Enforces configurable interface standards across enrollment channels, trading partners and custom enrollment file formats
  • Ensures complete enrollment audit reconciliation
  • Enhance analytical visibility of churn and produce performance

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