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Better member choices. Better outcomes. Better business.

If you have a use case that involves members making better choices, we have a solution to meet your health plan’s needs. Find out how we can help.

Softheon Solutions

Softheon solutions combine powerful technology and expertise hardened through years of real-world use to navigate members towards optimal outcomes, ensure healthcare program investments are optimized, and accelerate digital health guidance and adoption. All solutions are designed to foster better clinical, operational, and financial outcomes.

Medicare and Medicare Advantage members represent a highly vulnerable population with multiple chronic conditions such as diabetes, heart disease, and hypertension.

Softheon solutions can help you find and realize:

  • Increased closure of gaps in care
  • Improved STAR/HEDIS quality ratings
  • Faster member activation and engagement in  specialized care programs

20 percent of Americans use Medicaid, many with complex and costly needs for care. Most Medicaid members receive care through Managed Care Organizations (MCOs).

The complexity of the Medicaid population makes them often hard to reach and requires specialized engagement approaches. Often, socio-economic factors, health equity, and behavioral conditions play an important role in understanding the communication and engagement needs of this population.

Softheon solutions can help you:

  • Find the highest impact areas where member behavior can likely change
  • Better engage with this member population where they are at
  • Deliver faster and continued activation in specialized care programs
  • Help your members make better care choices that produce stronger outcomes and costs

Commercial health plans work hard to ensure members get the care they need when they need it. Still, a 2020 survey showed only 25 percent viewed their health plan as a trusted partner in their health and wellness.

You’re making investments in preventive and primary care services to provide excellent care while managing costs. However, your investments only work if members choose to use them when appropriate.

Softheon solutions can help you:

  • Find which segments need help and are likely to make better choices
  • Engage with member populations to shift behavior and perceptions
  • Shift member choice to programs and care services that deliver impact and ROI

Solutions that Drive Outcomes

Softheon solutions apply sophisticated technology and scientific rigor to create and activation and engagement engine tuned to create positive outcomes across your use case landscape. Here’s the flow of our solutions:

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Solutions by Health Plan Focus Area

Our solutions are tailored for the areas in your organization where member behavior and choice have a high impact on outcomes and financial performance.

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Help your members choose to participate in care management programs that improve outcomes with a specific focus on virtual care management programs. Activate more members into care, sustain that engagement, and optimize enrollment. Do it all while ensuring members with particular attributes are activated into programs that deliver the best outcomes. Here are example use cases of potential focus areas for your organization:

  • Behavioral health
  • Diabetes
  • Physical therapy/ musculoskeletal/ pain management
  • Falls prevention
  • Remote monitoring
  • Home dialysis
  • Remote asthma monitoring
  • Maternity – Doulas
  • Maternity – Diabetes
  • Hypertension
  • Cardiovascular health
  • Gastroenterology/ digestive health
  • Women’s health


Our solutions for utilization management help you to influence members to move to appropriate, cost-optimized sites of care. Three examples of the types of use cases which apply include:

  • ER redirect—Members with low acuity conditions redirected from the emergency room to PCP, urgent care or telehealth;
  • OON provider redirect—Members redirected away from low quality, high cost out of network providers to high quality, low cost in network providers;
  • Physical to virtual PCP redirect—Members redirected from in person PCP to virtual with such members further re directed to lower cost of care Rx sources by such virtual providers.
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Softheon solutions within risk management focus on accurate payer risk categorization of the member population within government lines of business including Medicare, Medicaid, and Exchange. Use cases this arena include:

  • Annual Wellness Visits—Activate more members with predicted but not captured HCC codes to AWV via PCP (in person)
  • Activate more members into home health visits
  • Increase the rate of home health assessments
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Provider management solutions focus on creating collaboration between payor and provider—where the provider is the engagement channel to those members who should have improved cost outcomes and improved quality ratings if successfully engaged. Members successfully targeted by providers could also trigger gain share reimbursement via Value-Based Care (VBC) agreements. Specific use cases in this solution set include:

  • Member steerage
  • Value based care – pay for quality
  • Value based care – pay for performance
  • Value based care – episodic payments
  • Value based care – shared savings
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Softheon solutions in this area help ensure members continue to choose your health plan as they transition from one line of business to another line of business. It also helps ensure the retention of members within your existing line of business through continued engagement optimization. Example use cases include:

  • Targeting increased member migration from your commercial plans to your Medicare Advantage plan
  • Ensuring members continue to choose your Medicare Advantage plan year after year
  • Persuading members to continue to use your Exchange plan offering
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Nexthealth solutions for quality and ratings improvement target areas that are evaluated by CMS to determine STAR/HEDIS ratings and where improvement is often accomplished via member interventions. Use cases are drawn primarily from measures within the categories of Effectiveness of Care, Access/Availability of Care, Experience of Care and Utilization. Example use cases include:

  • Cancer screening
  • Colorectal cancer screening
  • Annual wellness
  • Mammograms
  • Bone density scan
  • Vaccine booster
  • Diabetic eye examMedication adherence
  • CAHPS survey
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Softheon solutions help health plans demonstrate the value of different programs offered to employers. The solutions also operate in an “Intel Inside” capacity, working behind the scenes to help ASO client members make better choices. Example use cases include:

  • Justifying “buy-ups” such as care management programs offered by the health plan
  • Activating and engaging more ASO client members in care programs that improve outcomes and optimize health plan and ASO spend

Our solutions are helping members make better choices everyday. Isn’t it time your members started making better choices too?

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