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Population Payment Management

Accelerate the shift from paying for volume to paying for value by scaling value-based partnerships between health plans and providers.

Edifecs Population Payment Management solves the most pervasive challenges health plans face with scaling their value-based care and reimbursement initiatives. These challenges are solved through targeting and modeling populations and financial arrangements, automating program management and enabling on-going program optimization.

Solution Spotlight

  • Population Payment Management

    Edifecs Population Payment Management enables health plans to seamlessly scale and efficiently manage their shared savings, episodic and P4P programs. It models and analyzes impact of shifts in reimbursement from fee-for-service to value-based care payment model. Health plans can perform "what-if" analysis of future medical costs and gain enhanced intelligence into risk of their member population via risk stratification. Flexible templates reduce program design complexity and impactful analytics improve performance for both health plans and providers while also enhancing provider buy-in.

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  • Episodes of Care Module

    Edifecs Population Payment Management Episodes of Care Module automates the complete episode management lifecycle, from design to management to audit and reconciliation with external third party payers. It evaluates historical and current performance of providers to identify preferred episode collaborators. IDNs, hospitals, physicians and post-acute care providers can leverage the module to manage alternate episode-based payment models such as Comprehensive Care for Joint Replacement, bundled payments including common cardiac, oncology care etc.

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  • Shared Savings Module

    Edifecs Population Payment Management Shared Savings Module operationalizes shared savings program from design to management to audit and reconciliation with external third party payers. Pre-defined and custom program templates expedite the program design process. Health plans can perform budget analysis and projections and monitor progress of ongoing shared savings programs, review provider performance, perform payment settlements and generate shared savings reports.

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Edifecs Population Payment Management provides a flexible solution to manage the complex operational, financial, modeling and analytics requirements for value-based programs while ensuring visibility for all program stakeholders.

Drive program success via targeted alignment

Deftly target specific provider networks and member populations:

  • Identifies, attributes and maintains the alignment of specific providers and networks to select member populations
  • Analyzes target population to identify cost savings
  • Identifies high-risk populations and high-cost utilizers based on chronic conditions
  • Determines target populations and facilitates the selection of the most appropriate financial model

Fluidly design program and financial parameters:

Model and analyze financial arrangements. Leverage program templates

  • Performs "what-if" analyses on budget calculations, risk adjustment methodology and member attribution
  • Seamlessly leverage the results of “what-if” analyses/modeling to generate custom program designs
  • Leverage out-of-the-box program templates based on MSSP and other commercial health plan templates
  • Enhances the ability to predict future cost of service utilization

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Insightfully manage program performance through stakeholder visibility

Ensure complete and timely financial and population health transparency

  • Supports extensible payment workflows including reviews/approvals and denials
  • Timely, actionable reports and dashboards highlighting KPIs, metrics and budget/savings calculations
  • Enables “at-a-glance” review of the program performance of all alternative payment initiatives
  • Leverages Edifecs "big data" platform to streamline data connectivity and insights

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Scale program initiatives through automation and transparency

Intelligently optimize program operations and drive value-based care and reimbursement initiative scalability

  • Identifies and facilitates program design changes (such as moving to a two-sided risk model earlier) based upon provider performance
  • Enables decision support for use by health plans during program renewal with providers Provides dashboards and reports for health plan sales and marketing teams to effectively communicate program benefits to employers and plan sponsors
  • Delivers a robust and highly scalable platform which enables bringing pilot projects to enterprise and community level
  • Reduces data lag due to disconnected systems

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