Better member choices. Better outcomes. Better business.

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.

CARE MANAGEMENT

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:

UTILIZATION MANAGEMENT

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.

RISK ADJUSTMENT

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

PROVIDER NETWORK PERFORMANCE

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

Group of healthcare workers with digital tablet meeting in hospital boardroom. Medical staff during morning briefing.

MEMBER ACQUISITION & RETENTION

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

QUALITY & RATINGS IMPROVEMENT

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:

Group of healthcare workers with digital tablet meeting in hospital boardroom. Medical staff during morning briefing.

ASO COMPETITIVE PARITY & DIFFERENTIATION

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: