Mitigating waste in healthcare with analytics and interventions

Blog Posts  |  04 January 2019

It has been estimated that a third or more of what the U.S. spends annually on healthcare could be eliminated without impacting the quality of care.1 The majority of ineffective spending can be attributed to inefficient health administrative practices, as well as failures in care delivery, care coordination and/or overtreatment.

In our previous discussion on mitigating waste in healthcare/provider information exchanges, we reviewed how manual processes such as patient chart exchanges, gap in care communications and electronic prior authorization can be easily automated to help cut waste from the healthcare system. In this second article, we will review how health plans can leverage advanced analytics, predictive techniques and targeted interventions to achieve quality outcomes while yielding the improved return on investment (ROI).

Maximize quality measures

Health plans are under constant pressure to improve quality of care, increase Medical Loss Ratio (MLR) and maximize risk adjustment opportunities. But knowing where to focus limited resources and how to avoid pursuing low-yield interventions is a significant challenge.

Precise targeting analytics and predictive modeling techniques can help health plans understand member population risk factors and identify focus areas with the highest potential to yield desired results. Here are a few examples of key opportunities:

Detect: Addressed by:
Risk adjustment and quality improvement opportunities

Targeting gap in care interventions that have the greatest impact
Highest audit risk areas

Focusing medical record review where highest ROI can be achieved
Hierarchical Condition Codes (HCCs) or condition types with the most risk

Zeroing in on patients and conditions where care management programs can be most effective


Today’s more sophisticated models also produce “chase lists” that provide actionable steps to target the right member at the right time with the right intervention.

Deliver effective payer-to-provider communications

Health Plan-initiated messaging tools that facilitate communication between payers and providers can achieve efficiency and maximize ROI by communicating gap in care information where and when it is most useful - at the point-of-care. By delivering actionable direction to close the gap in care in the right place at the right time, health plans can maximize their ability to influence providers.

What many health plan leaders may not be considering is that these tools can also facilitate payer-provider exchanges around claim coding to ensure the proper level of detail is submitted. Ensuring each claim includes details on all possible diagnosis codes for the encounter is critical to maximizing risk scores.

This is especially significant due to the transition from the Risk Adjustment Payment System (RAPS) to Encounter Data Processing System (EDPS) for Medicare Advantage where more detailed information is required to obtain proper reimbursement.2 Effective communications around claim coding can enable both payers and providers to take full advantage of risk adjustment scoring and maximize reimbursement.

Strengthen member engagement

Health plans can engage members and promote care plan compliance by using Mobile Customer Relationship Management (mCRM) systems. One study revealed that 83% of Americans don’t follow treatment plans given by their doctors exactly as prescribed and 42% feel they would be more likely to follow their prescribed treatment plans if they received encouragement and coaching between visits.3

mCRM tools can improve the patient/member experience and enhance the quality of care by proactively contacting members to drive them in for needed services. Automated outreach by these tools includes:

  • Proactive reminders to schedule needed appointments
  • Action items created for members to address gaps in care and promote care plan adherence
  • Recommendations for use of an in-network provider to address a specific condition
  • Concierge-style member services and support such as scheduling appointments
  • Education for members on cost-saving options to discuss with their doctor during the visit
  • Post-care instructions and follow up
  • Post-care adherence support including medication reminders

Health plans can take advantage of these tools to enhance member engagement with Care Management programs, HEDIS® quality improvement initiatives or any member support effort.

Veradigm Solutions – Transforming Health, Insightfully

Veradigm is committed to helping Health Plans and other partners effectively meet these challenges with solutions that balance driving quality outcomes while maximizing ROI:

  • Maximizing quality measures – Pulse8 solutions combine advanced risk adjustment analytics with big data mining and clinical inferencing models to improve your predictive capabilities and strategically prioritize risk adjustment and quality improvement initiatives to maximize ROI.
  • Deliver effective payer-to-provider communications – Veradigm’s point-of-care messaging solutions deliver communications addressing gaps-in-care, claim detail or other topics important to payers directly into each provider’s existing workflow.
  • Strengthening member engagement – FollowMyHealth® is a mobile-first platform that makes it easy to stay engaged with your members where they are and at every step of care with personalized information and instructions pre-care, at the point-of-care and post-care.



1 “Reducing Waste in Health Care,” Health Affairs Health Policy Brief, December 13, 2012. DOI: 10.1377/hpb20121213.959735

2 HealthIT Outcomes, Understanding The RAPS — EDPS Transition And How To Mitigate Revenue Loss, September 22, 2016

3 HealthIT Outcomes, The Shocking Truth About Patient Engagement, September 6, 2012