TheHealthcare360, an interactive, fully integrated, and AI-based platform with multi-module solutions, focuses on resolving many issues participants in the Medicare, Medicare Advantage, Medicaid, and commercial domain face every day. Some major issues we resolve are:
Inability to identify HCCs, quality, submissions, and visits gaps resulting in lost revenue.
Inefficient and costly programs and processes to close gaps generating undesirable ROI.
Missing standards for performance, scorecards, and peer to peer comparison resulting in underperforming providers.
Extensive IT backlog for required custom dashboards and reports reducing valuable insight to run RA programs resulting in unsuccessful programs.
Inability to trend and predict revenues, costs, utilization, and care resulting in unexpected financial shortages.
Limit of visibility to identify RAFs by segments (like the members, plans, centers, providers, and others) causing poor focus and resulting in inefficient programs.
Inefficient coding process due to outdated or manual tools and excessive irrelevant documents resulting wasted time and money.
Multiple formats of complex files, documents, and compliance requirements by CMS resulting in excess cost.
Limited subject matter experts and highly skilled healthcare IT resources resulting in unsuccessful and costly programs.
How We Solved It
Developed AI-based integrated model to bring data, systems, and people together to manage Risk Adjustment programs in an Ideal way.
TheHealthcare360 Product Suite Modules
This member-centric module provides 360° insight about your members. It compares current demographic and health status to historical statuses and predicts future status. This results in better membership management by closing gaps in the member’s healthcare and quality measures.
This module focuses on providers to measure and enhance the quality, completeness, and efficiency of the services provided to the patients. It provides in-depth statistics and analytics to highlight any provider’s gaps and issues and how to resolve it.
The heart of the Risk Adjustment program is the RAF360. The focus is on membership RAF: Defining the current RAF, past RAF, future RAF – what it will be, and what it should be. Our goal is to identify all gaps and predict possible gaps to capture by using complex and validated analytical models.
This module identifies the current quality measures status, identifies the gaps, and provides possible ways to close them which will help improving quality performance metrics like HEDIS and STARs. Self-Managed AI-based module that allows you to update your measures status as frequently as needed.
This module includes a clinical coding tool that has automated NLP-based charts and data review processes which allows organizations to capture various data like diagnosis codes, procedure codes, quality measures, and much more.
This module focuses on cash flow and the RA payment models and processes to help organizations identify what likely payment when they should receive payment, and identify any gaps in payments.
This model provides a 360° view of claims. It allows users to slice and dice the complex claims data to provide answers to business questions like utilization, costs, and statistics easily. In addition, it utilizes claims data to get an accurate PMPM and to identify possible ways to reduce it
This model provides a complete picture of submissions. It reconciles what has been submitted with what should have been submitted. Also, it finds the gaps, rejections, and other issues in the submission process then it creates files to submit missing data.