Health Plans

Leveraging AI Data to Improve Health Plan Performance

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Removing data silos through an AI-enabled platform

Edifecs is eliminating the siloed vendor framework that health plans have endured managing enrollment, risk adjustment, chart retrieval, submissions, and information exchange efforts. With our integrated approach, you can have an end-to-end view of how your government-sponsored populations are performing to improve payment accuracy and provider relations to reduce compliance, coding, and data errors.

Infographic - Health Plans


Smart Trading

The need for the continual real-time transformation, sharing, scalability, and secure storage of information is at an all-time high with more people transitioning to permanent remote work. Additionally, companies, customers, and partners have become more globally distributed. Smart Trading is a wireless ecosystem that enables more scalability, better security, and faster sharing of information across multiple locations and workstations.

  • Simplify clinical data integration and comprehensive support for interoperability standards
  • Modernize and unify healthcare transaction processing and flow through a single channel
  • Improve tracking and visibility into transaction flow and bottlenecks

Enable interoperability, assure compliance, correlate clinical and administrative data, and deliver real-time visibility of each partner’s data exchange

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Risk Adjustment Workflow

As enrollment continues to grow, the risk adjustment burden keeps rising – as well as the associated costs. Traditional, manual approaches to risk adjustment are siloed, resource-intensive, error-prone, and do not scale with an organization’s growth. To ensure appropriate reimbursement for the risk factors present in government-sponsored populations, health plans need to accurately identify, document, and report risk scores.

  • Increase risk capture by 20-30% by accurately identifying HCCs that are commonly missed or coded improperly in manual reviews
  • Optimize coder efficiency through a prioritized case list that presents only those records requiring a review, thereby reducing coding volume and decreasing time spent per record with all supporting evidence linked to the member
  • Ensure accurate, complete, and compliant encounter submissions

Identifies, manages, and documents member risk across all product lines, ensuring complete and accurate payments payments through our modular, EHR-integrated solution

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Value-Based Payment & Insight

Value-based payment initiatives have moved beyond isolated pilots for micro-segments of members and providers. Today’s healthcare organizations need sophisticated technology to manage complex programs across all payment models and lines of business.

  • Standardize and automate the management and growth of value-based payment contracts in provider networks
  • Establish corporate standards and global rules for value-based payment contracts
  • Provide transparency in payment methodology and reporting between stakeholders and decision-makers (payers, providers, members, partners)
  • Comply with state and federal value-based mandates and reform targets

Enable targeted, scalable, and repeatable value-based program contract development and administration

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Enrollment Management

Consolidate traditionally disparate systems and automate manual processes with our modern, centralized enrollment platform that orchestrates data streams for all lines of business. Health plans gain new visibility, operational efficiencies, and faster onboarding times while safeguarding revenue with financial reconciliation.

  • Reduce manual intervention and processing spend through automation and intelligent workflows, resulting in lower costs and fewer data errors
  • Enable self-service capabilities for member coverage maintenance, corrections, and audit discrepancy reviews
  • Automate upfront data validation and system-wide orchestration

Modernize and consolidate member enrollment operations for internal teams and external partners

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Prior Authorization

By leveraging AI technology, X12 278, FHIR standards, and existing EHR integration to standardize the prior authorization workflow, you can improve member experience, enhance outcomes, and reduce administrative burden.

  • REDUCE costs associated with an inefficient prior authorization process​
  • REMOVE provider abrasion through EHR integration​
  • ENHANCE consumer experience and outcomes with a faster review process​
  • COMPLY with evolving state and federal legislation​
  • CONSOLIDATE vendors with a single end-to-end prior authorization solution​

Fully automate prior authorization at the point of care through utilization management to reduce cost, ensure ongoing compliance, and establish better collaboration with providers

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