Payers

As a payer, your biggest enemy is the unknown

Understand member risk like never before. Use new clinical insights to improve performance across your organization, from underwriting and risk adjustment to prior authorization and utilization management. That's emtelligent.

blur image Get the complete picture of health

Risk Adjustment

  • Unlock hidden risks in member medical records that are undetectable with traditional claims data
  • Close previously unknown care gaps to increase risk adjustment performance
  • Improve efficiency by significantly reducing the need for manual chart review

Medicare STARS & HEDIS

  • Leverage clinical notes to gain a full picture of member history and needs
  • Drive improved STARS and HEDIS program performance by leveraging the full clinical record to identify care gaps and opportunities
  • Uncover new insights to improve clinical quality and augment data from other provider programs

Prior Authorization

  • Rapidly review a patient's full medical record when seeking supporting evidence for an approval or denial
  • Eliminate costly and time consuming manual review efforts with reliable and auditable chart summaries, focusing your clinical teams on higher value activities
  • With the emtelliPro+ assistant, import policy details and supporting business-rules to make approval determinations and automate letter development

Underwriting

  • Leverage the full clinical record in addition to historical claims data to pinpoint risk in both existing and prospective member populations
  • Use new risk data to more accurately price products across your portfolio

Care & Disease Management

  • Pinpoint details about your members' health history otherwise unknown from claims data
  • Increase eligibility for all of your clinical intervention programs, improving your ability to impact outcomes and costs
  • Gain insight into valuable member background information and contributing factors like social determinants of health

Payment Integrity

  • Connect data in the clinical notes to claims details to reduce claim errors and ensure accuracy
  • Improve auto-adjudication rates and payment accuracy while reducing fraud, waste, and abuse and subrogation impacts
  • Accelerate audits and improve ROI by eliminating costly manual record analysis during investigations

Member Engagement

  • Leverage insights from patient records to improve click-through rates on member reminders and next best action opportunities
  • Refine personalization strategies and tailor recommendations based on the experiences and care needs of individual members

80%

of clinical data is unstructured and inaccessible outside of a costly and time consuming manual review process

Payers are faced with terabytes of clinical data in a variety of formats, across multiple silos and business units.

Our payer customers are actively using emtelliPro and emtelliPro+ to power clinical transformations that organize their disparate data and surface the insights needed to fuel their business.

  • Identifying hidden population risk
  • Discovering pricing and cost savings opportunities
  • Improving care team productivity
  • Powering custom app development
  • Advancing analytic needs

...and much, much more.

How it Works

Our work in the industry

Large National U.S. Healthcare Payer

Our engagement team developed a plug-in to accelerate the discovery of unstructured clinical data by unbundling the CCD - the industry-wide standard for the exchange of health information - structuring the unstructured elements, and connect it with the document's existing structured data.