It’s difficult to believe in less than 100 business days, open enrollment begins for the new Commercial Health Insurance Marketplace.

How are you preparing your network, systems and infrastructure for Risk Adjustment?

The unique characteristics of the Marketplace require the use of predictive analytics that reach beyond claims data, improve confidence levels, and realization rates that positively impact qualified health plans (QHPs) performance.  The combination of multiple data sources, medical and non-medical, significantly improves the accuracy of a population’s health complexity required to be competitive in the new marketplace – enriching QHP Risk Adjustment Factor and containing cost.

Here are some things QHPs could do now, prior to October 1, 2013 to prepare provider networks, systems and infrastructure for commercial risk adjustment:

1. Perform analysis of conditions most susceptible to documentation issues in existing population
2. Identify and prioritize condition sources
3. Establish performance benchmarking of providers requiring targeted education
4. Evaluate and identify possible coding and abnormalities at the provider and group levels
5. Analyze provider specialty patterns and sequencing for inappropriate diagnoses
6. Integration to ensure providers adhere to health care standards for the exchange
7. Establish online health self-assessment tools for new enrollees to complete
8. Deploy mobile applications to educate new members about wellness and interventions

Pulse8’s collaborative approach and visibility tools offer you the ability to create customized Risk Adjustment strategies, integrate most recent findings, and adjust throughout the program to achieve optimal financial performance.  To learn more about our Products and Methodologies that will help you prepare your Risk Adjustment Strategy for the Commercial Health Insurance Marketplace click on our product menu “Health Exchange Suite”.

To learn more: http://www.pulse8.com/health-insurance-exchange-hix/

Pulse8’s Health Exchange Suite^TM products provide an unprecedented view into Risk Adjustment activities, behaviors, interventions, and data that give health plans the opportunity to quickly address risk adjustment factors, diagnosis trends, quality scores, and comparative performance metrics.  Mr. Criswell explains “Pulse8’s strategy allows us to quickly customize the approach by implementing complex algorithms, predictive models, and interventions for each plan and metal level, and to adapt to differing models implemented by each state”.

Mr. Criswell recognizes the unique characteristics of the Health Insurance Exchange Marketplace and the necessity to reach beyond claims data when applying predictive analytics and risk adjustment solutions.  Pulse8’s unique use of medical and non-medical data sources significantly improve the accuracy of predictive models and other analytic tools, thus allowing a health plan to be competitive in the exchange marketplace.

HHS uses the concurrent risk adjustment model that compresses timelines proposed for the Health Insurance Exchange Marketplace making collecting accurate and meaningful data from providers a critical focus for health plans. Pulse8 offers unique data collection tools, including mobile applications that allow providers insight at the time of the encounter while providing health plans a direct data feed following a member’s visit.

Mr. Criswell emphasized the need for plans to directly engage their members.  He stated, “The lack of patient data could cause loss of revenue, increased utilization, increased cost, and missed benefits. Closing this data gap early improves quality of care and enhances revenue opportunities”.  Pulse8 is at the forefront of capturing member-provided data using mobile technology.

Pulse8 provides health plans with the ability to leverage and scale existing infrastructure and systems with independent and informed analytics, data collection tools, and integration systems connecting every component of the medical system from provider to patient.

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If you would like more information about Pulse8, please visit www.pulse8.com. To schedule an interview with John Criswell, please contact the Marketing Department at 410-928-4218 or email info@pulse8.com.

Increase Revenue and Reduce Cost

Provider and Member-reported data is critical in driving interventions to improve risk scores.

Pulse8 offers an innovative suite of Data Integration and Collection Methodologies to fulfill every provider integration scenario.

Key Features and Benefits:

• HL7 Integration ensures that providers adhere to health care standards for the exchange, integration, sharing and retrieval of electronic health information that supports clinical practice and the management, delivery and evaluation of health services.
• Online Assessment Tool
• Provider Report Portal
• Assessment Tools
• Mobile Applications

m8LINK™ Assessment Mobile Application collects Provider insight at the time of encounter with a direct data feed following a Member’s visit.  It is vastly customizable to each plan’s needs and extremely easy to deploy.

Delivering Benchmarking Visibility Across the Network

Simple navigation through our software allows the user to drill down from plan-level information to a provider group, individual provider, or member.

Business Intelligence8 is your solution to:

• Tracking Provider practice and specialty patterns and clinical outcomes
• Tracking Member behaviors in addition to their conditions for a comprehensive Member profile
• Sequencing for inappropriate diagnoses

Our Business Intelligence8 with reporting tools are delivered via our transparent dashboards.

Key Features and Benefits:

• Highly configurable and customizable to produce the most detailed or high-level status and results for all stakeholders
• Pushed directly to web-based products viewable anywhere with Internet access or downloadable for offline viewing and sharing across individuals and departments
• Available immediately – all results can be immediately imported in real-time with vendors – to view and track performance against expectations and key milestones

Your Key to Risk Accuracy & Audit Readiness

HHS requires each plan, regardless of its size, to have an independent auditor to preform the initial data validation audit.  The state, or HHS on behalf of the state, will adjust plan-level risk scores based on these audits.

It is imperative that QHP’s have real-time Risk Adjustment Intelligence –  transparency and visualization capabilities that align Risk Adjustment factors to its population’s relative complexity.  This capability will improve the integrity of the plan’s data in preparation for an audit.

Key Features and Benefits:

• Analysis of conditions most susceptible to documentation issues
• Identification and prioritization of condition sources
• Performance benchmarking of Providers requiring targeted education
• Evaluation and identification of possible up-coding and abnormalities at the Provider and Group levels
• Provider specialty patterns and sequencing for inappropriate diagnoses

Data Sources

• Health Claim Data
• Prescription Histories
• Laboratory Histories
• Electronic Health Record Data
• Imaging Data
• Durable Medical Equipment Data
• Health Risk Assessment Data

Early Detection and Prevention

• Hypertension
• Pre-Diabetes
• Diabetes

• Diabetic Retinopathy
• Glaucoma
• Macular Degeneration
• Wellness
• Lifestyle
• Stroke
• Circulatory Disease

Pulse8™ Stratification methodologies are designed to use the data to create an estimate of risk (or probability) that support the most effective intervention type. The probabilities are assigned to members based on the results of predictive models that Pulse8 runs in its propriety environments. The models work by assigning a weight to each of the possible risk factors that a person has and then computing the risk. In looking at all of the outputted risk scores, the algorithms can then assign individuals into groups or “strata”.

Pulse8™ evaluates the Stratification output using Event Sequencing tools to compare individuals based on the time since they experienced a sentinel event. The analysis of patterns and chronic disease pathways is useful to maximize the individualss next intervention.

Pulse8™ Provider Profiling

Medical professionals in the dynamic healthcare environment demand more real-time information on their patients. Providers understand the multitude of data points associated with each patient they see, yet the majority of that data is unavailable to them or presented in ways that each provider cannot easily extract the knowledge needed to impact the care at the time of service.

Pulse8™ builds unique profiles of each provider to allow each payer to understand the metrics and behaviors of their providers. Providers are the essential element in transforming traditional point-of-service care into an interwoven quality of care model for the exchanges, transmitting real-time data between the provider and the plan to obtain actionable information is critical for success.

Pulse8’s profiles provide an unprecedented view into activities, behaviors, volumes, and data that give payers to quick access to address diagnosis trends, quality scores, and comparative performance metrics.

Pulse8™ Member Profiling (adults, children, infants)

With the Department of Health and Human Services guidance on the type of risk adjustment models applicable to health insurance exchanges, building a comprehensive member-level profile has never been more important. These complex profiles greatly expand the traditional risk adjustment models to include a much broader and less homogenous adult population as well as separate models for children and infants.

Pulse8™ developed our risk adjustment algorithms from the ground up – informed by millions of health data sets, health event sequencing, groundbreaking health data research, ancillary health data, and statistical modeling. Our member profiles were built to support a proprietary approach customized for the uniqueness of state-based exchanges and the payers in each market. Pulse8™ Risk Adjustment Analytics our uniquely independent. Payers will discover Pulse8’s approach to the health insurance exchange model as effectual, precise, and adaptable to differing state-based models and client requirements.

Our Proprietary Game-Changer

Reveal8 is Pulse8′s Risk Adjustment analytics solution that uses advanced informatics, predictive modeling, and medical ontologies to provide qualified health plans (QHP) and providers with an intelligent population and individual-level risk adjustment application.

Key Features and Benefits:

• Pulse8’s analytics drive precision and accuracy to reflect the actual health complexity of the patient population
• Pulse8’s analytics target patients that are more complex and assist them in navigating the healthcare system to find the most appropriate care
• Pulse8′s prediction model enables a personalized intervention supporting the provider on what the individual patient requires next improving quality and reducing cost

Our algorithms are developed by clinicians, biostatisticians and statisticians who combine advanced medical knowledge and evidence-based guidelines with statistically valid rule sets.

Pulse8™ Stratification Methodologies

Pulse8™ Stratification methodologies are designed to use the data to create an estimate of risk (or probability) that support the most effective intervention type. The probabilities are assigned to members based on the results of predictive models that Pulse8 runs in its propriety environments. The models work by assigning a weight to each of the possible risk factors that a person has and then computing the risk. In looking at all of the outputted risk scores, the algorithms can then assign individuals into groups or “strata”.

Pulse8™ Sentinel Methodologies

Pulse8™ evaluates the Stratification output using Event Sequencing tools to compare individuals based on the time since they experienced a sentinel event. The analysis of patterns and chronic disease pathways is useful to maximize the individualss next intervention.

Pulse8™ Provider Profiling

Medical professionals in the dynamic healthcare environment demand more real-time information on their patients. Providers understand the multitude of data points associated with each patient they see, yet the majority of that data is unavailable to them or presented in ways that each provider cannot easily extract the knowledge needed to impact the care at the time of service.

Pulse8™ builds unique profiles of each provider to allow health plans to understand the metrics and behaviors of these providers. Providers are the essential element in transforming traditional point-of-service care into an interwoven quality of care model for the Marketplace.  Transmitting real-time data between the provider and health plan enables the plan to quickly address diagnosis trends, quality scores and comparative performance metrics.

Pulse8’s profiles provide an unprecedented view into activities, behaviors, volumes, and data that give payors to quick access to address diagnosis trends, quality scores, and comparative performance metrics.

Pulse8™ Member Profiling

With the Department of Health and Human Services guidance on the type of risk adjustment models applicable to health insurance exchanges, building a comprehensive member-level profile has never been more important. These complex profiles greatly expand the traditional risk adjustment models to include a much broader and less homogenous adult population as well as separate models for children and infants.

Pulse8™ developed our risk adjustment algorithms from the ground up – informed by millions of health data sets, health event sequencing, groundbreaking health data research, ancillary health data, and statistical modeling. Our member profiles were built to support a proprietary approach customized for the uniqueness of state-based exchanges and the QHP in each market. Pulse8™ Risk Adjustment analytics are uniquely independent. QHP’s will discover Pulse8’s approach to the health insurance exchange model as effective, precise, and adaptable to differing state-based models and client requirements.