Veradigm Payer Solutions is a comprehensive, end-to-end solution designed to help health plans, payers, PBMs, and insurance companies balance cost control with the goal of providing high-quality care and optimizing member health outcomes. The suite is built on the Veradigm Network, which drives value at the intersection of payers, providers, and life science organizations.
Key Components and Capabilities:
- Health Plan Analytics (Veradigm Quality Analytics): Identifies gaps in quality measures like Star Ratings, Quality Rating Systems, and Pharmacy Quality Alliance measures. It includes an NCQA Certified HEDIS engine to help close quality gaps and improve quality scores cost-effectively.
- Risk Adjustment (Veradigm Risk Adjustment Analytics): Assists finance, medical management, and quality teams with precise, advanced risk adjustment algorithms built from broad data sets for superior accuracy, aiming to maximize financial performance and clinical outcomes.
- Bi-directional Clinical Data Exchange (Veradigm eChart Courier™): Improves efficiency by automating the medical chart retrieval process for HEDIS submissions and other data collection, facilitating high-speed clinical data exchange between payers and providers.
- Clearinghouse & EDI (Veradigm Payerpath's EDI Gateway): Solves Electronic Data Interchange (EDI) challenges by creating a single point of contact for seamless connection with providers, regardless of their clearinghouse. It offers unified file processing and pre-adjudication edits to simplify claims and reduce errors.
- Care Gap Alerting (Veradigm Payer Insights): Integrates patient-specific care gap alerts directly into the Electronic Health Record (EHR) workflow of network providers, delivering real-time, actionable insights to improve care and reduce administrative overhead.
The platform leverages newer technologies like Artificial Intelligence (AI) and machine learning to enhance predictive modeling, allowing payers and providers to identify high-risk patients sooner. It is committed to embracing FHIR standards and industry-standard protocols like APIs to streamline data sharing and interoperability.
