Help Your Members Make Better Choices

Care management use cases involve getting more members involved in care management programs proven to improve outcomes. These programs drive better activation into care, sustained engagement, and optimized enrollment.

Utilization management use cases involve influencing members to access care via appropriate but less costly sites of care. Areas of focus include redirects from high-cost, less optimal settings to more appropriate alternative physical and virtual settings.

Provider network performance use cases focus on creating collaboration between payor and provider. It targets members who are likely to realize improved outcomes which results in better quality ratings. It also helps providers maximize VBC contract reimbursements with the payer.

Risk adjustment use cases focus on helping the payor receive appropriate reimbursements based on the health of their membership. This applies across lines of business (Medicare, Medicaid, and Exchange) and fosters improvements in areas which help accurately identify and accurately capture HCC codes.

Quality and ratings improvement use cases focus on improving member health through better care, such as improving the rate at which members receive wellness visits, vaccines, diabetic eye exams, cancer screenings, and similar care. Improved activation into these care settings also improves STARS and HEDIS ratings for plans.

Member acquisition and retention use cases today fall under key business areas such as increasing commercial member conversions to Medicare Advantage plans and improving member retention for both Exchange and Medicare Advantage.

Competitive parity and differentiation use cases focus on validating the value and competitive advantage of various internal and third-party vendor programs provided by payers. Example use cases include things like justifying the value of care management programs offered to employers (often called "buy-ups") and supporting health plan initiatives with ASO clients to engage employees and improve outcomes.