Success in the story
Founded nearly a century ago, the Regional Health Insurer is a health and wellness company focused on insurance plans, including primary and specialty care, and wellness solutions. It serves more than three million people in the northeastern U.S.
The Regional Health Insurer is no stranger to navigating the challenges of the health care industry. Today, health care is more complex than ever, which continues to inspire the Regional Health Insurer’s commitment to delivering quality care at an affordable price.
The risk adjustment leadership team at the Regional Health Insurer includes several team members, including ones with extensive experience in risk adjustment. These team members helped to set the expectation that a trusted partner would be essential to their provider engagement experience.
People, products, and processes
Together, the team selected Veradigm to be that partner. People, products, and processes Veradigm and the Regional Health Insurer have partnered for many years on risk adjustment. Both understood and agreed that to achieve the best outcomes, you must invest not only in products, but also people and processes. Veradigm’s Senior Manager of Provider Engagement Amanda Banister worked closely with the risk adjustment leadership team, Regional Health Insurer to align people, products, and processes.
Partnership is about people, and Veradigm and the Regional Health Insurer collaborate regularly. Via kickoff calls, scheduled provider calls, or performance reviews, both teams work together in lock step to ensure that common goals are achieved. Risk adjustment is a marathon and not a sprint, side by side every step of the way the teams trained with continuous education and investment into people and providers.
“Veradigm Collaborate is more than just a product name to us, we recognize the importance behind the product and understand that collaboration between payers and providers is crucial,” shared one member of the risk adjustment leadership team, Regional Health Insurer.
From people, the Regional Health Insurer next looked to the product solutions. The solid foundation required for success is hard to achieve. The Regional Health Insurer built its risk adjustment program on the foundation of Veradigm Payer Analytics’ comprehensive set of risk adjustment and quality solutions for payers, including Veradigm Risk Adjustment Analytics (RA gap identification) Veradigm eChart Coder (automated chart coding), Risk Mitigator (coding risk identification), and EDI Translate (electronic data interchange). Last but certainly not least, it elected to utilize Veradigm Collaborate, a provider engagement system which helps address gaps in care related to a patient’s condition and quality of care, so payers can code correctly and precisely, and to identify patients who require follow-up due to gaps in care or are at high risk.
Through the use of these Veradigm Payer Analytics solutions, Regional Health Insurer saw marked success including:
- Closed appropriate risk adjustment gaps
- Received feedback from clinicians on conditions member does not have
- Achieved more accurate and complete risk scores
- Deployed the right intervention, with the right provider, at the right time
With the cornerstones of the people and products in place, together the Regional Health Insurer and Veradigm moved on to the process. Both teams recognized that a good process was not enough if they wanted to evolve their risk adjustment results from acceptable to optimal, they would need a fully comprehensive process. Together the two teams developed and bought into a best practice model for people and utilizing products exactly as intended, to their fullest capability–and the result was achieved goals.
“The Regional Health Insurer came in to 2022 with a goal of 10 percent more completed provider alerts than their 2021 goal. A lofty goal in itself, but just a steppingstone in the right risk adjustment partnership. We’re proud to share that they ended 2022 with 45,797 completed provider alerts which was 25 percent higher than 2021,“ said Amanda Banister, senior manager of provider engagement, Veradigm.
Maintaining the momentum year after year
The Regional Health Insurer takes pride in meeting 2,500 providers where they are and being responsive to the needs of its network. This key principle is profoundly illustrated in the momentum and maintenance of the success of its risk adjustment statistics. Far beyond a single year of remarkable success in 2022, Regional Health Insurer has steadily built on continued momentum across the last several years:
“While one year of success is wonderful, we want more for our providers. By constantly investing in our provider success and implementing adaptive strategy, our team is proud to share four-plus years of year over year success in risk adjustment with Veradigm,” said a member of the risk adjustment leadership team, Regional Health Insurer. “Providers come to us and say, we wish all of our plans had such a successful tool to use.”
“We’ve also received feedback from multiple providers about the user-friendly experience working in the Collaborate platform,” noted a different member of the risk adjustment leadership team. “Making the process of completing an alert easy has contributed to the success of the program. The educational resources including the webinars and ’one-pagers’ have also received positive feedback and groups use them for their provider education sessions.“
Regional Health Insurer continually reinvests in its organization, members, and communities, and Veradigm will continue to partner in that process for success to help the Regional Health Insurer achieve its evolving goals.
Client Profile
OVERVIEW
- Regional health insurer with three lines of business
- A health and wellness company that provides insurance plans, primary and specialty care, and wellness solutions
- Not-for-profit health insurer, serves millions of people in the Northeast U.S.
- In business for nearly a century
VERADIGM SOLUTIONS
- Veradigm Risk Adjustment Analytics
- Veradigm eChart Coder
- Risk Mitigator
- EDI Translate
- Veradigm Collaborate
CHALLENGE
- Large, regional not-for-profit health insurer had developed an impactful risk adjustment program; however, it recognized that a significantly higher level of optimization of care was achievable.
SOLUTION
- The Regional Health Insurer and Veradigm came together in a committed partnership dedicated to optimizing their solutions and process to achieve mutual success through reciprocal investment.
OUTCOMES
- Regional Health Insurer year over year results – completed risk adjustment alerts
» 2019 goal: 13,000/Actual completions: 12,402
» 2020 goal: 16,250/Actual completions: 33,881
» 2021 goal: 29,719/Actual completions: 33,321
» 2022 goal: 36,654/Actual completions: 45,797
- At of the close of its 2022 risk adjustment program, the Regional Health Insurer had a total of 45,797 completed provider alerts for its 2022 Program Year, 25 percent higher than the goal it set for 2022 and a direct result of the benefits of a thoughtfully designed, evolved, and supported risk adjustment program.