• Payers (boxes to the left) send volumes of data to Providers in varying formats all manual (paper, fax, etc.).

    Time sensitive revenue opportunities are missed, information is highly fragmented and unreliable.

     

    Time is wasted on reworking issues, diverting resources away from care.

    Healthcare providers are empowered; improving revenue and saving time without asking for payers to do anything differently since Carenodes technology is engineered to sort manual work for the healthcare worker.

    Data is streamed in real time as well as ingested in batches. Each data element is imported as it is emitted by the source. In addition, data is imported in discrete chunks at periodic intervals of time. We prioritize data sources, validate individual files, route data items to the correct destination, and implement automatic tracking.

  • Reports Sent From Payers to Providers

    Time Sensitive Reporting from payers which have Quality + Revenue + Efficiency implications. Incredibly onerous to aggregate all of these reports which have a window of 90 to 120 days to be implemented. Past that window, incentive payout opportunity expires.

    Member Eligibility Files

    Monthly headcount indicating # of patients (members) assigned by a payer to a given provider. This information is used to arrange for screenings (which can be paid outside of capitation), allow for risk adjustment, and serves as monthly report as to revenue and member/patient assignments.

     

    Time and revenue sensitivity: High

    Gaps in Care (HEDIS, HCCs)

    Monthly: Payers identify gaps in preventive screenings for which a given primary care provider is responsible for 'closing'. These measures reset annually, hence, the process of conducting these preventive care screenings is ongoing. Healthcare providers can receive substantial incentive payouts for meeting targets and payers see a significant adjustment (+/-) to their top-line revenue based on the performance of their provider network.

    Resource Utilization

    Monthly: Hospital, Emergency Room, Skilled Nursing utilization (admissions, readmissions) -- requiring a follow-up from care team post-discharge. Providers rendering transitional care management services to patients listed on these reports can receive additional reimbursement for those efforts but only if rendered within a specific timeline (7 to 30 days). Payers can mitigate avoidable ER/hospital utilization when primary care providers render timely post-discharge follow ups.

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