Payer Gaps in Care

How It Works

Enli’s payer gaps in care solution converts payer-defined care gaps into a task-based workflow for care teams. Matching members on the payer list with patients in the EHR is completely automated. The need for manually reconciling hundreds or thousands of records each time a payer file is received is eliminated.

Matched patients are automatically placed into the workflow, where care coordinators can view patient-specific gaps across all payer contracts. They can filter by contract, number of care gaps, or measure to guide outreach and prioritize patients according to clinical and financial risk.

For each patient, payer data is compared side-by-side with EHR data through a simple user interface, highlighting possible data inconsistencies requiring action. Unmatched members are placed into a separate workflow that streamlines the reconciliation process.

Direct access to the complete patient record gives care coordinators the tools they need to evaluate care opportunities and schedule services for more productive patient encounters.

 

Automate the member-patient matching process for any payer gaps in care file

Automate Patient Matching

Members in the payer list with an exact match with patients in the EHR are automatically placed into the care gap workflow for care coordinators to begin outreach. The need for manual patient matching every time a payer file is received is eliminated.

Reconcile Suspected Matches

Members with a possible EHR patient match are placed in a reconciliation workflow, where health plan members are presented in a side-by-side comparison with suspected patient matches. Once a match is confirmed, the patient is automatically matched the next time the payer’s file is processed. This capability converts a burdensome recurring process into an efficient, one-time task.

Onboard New Patients

Members with no patient match in the EHR can be placed in a separate workflow for new patient onboarding or review with the payer. This enables practices to rapidly engage and onboard patients that are assigned by the payer but have never seen the provider.

 

Compare payer data with EHR data to surface inconsistencies

Normalize Contract Measures

Clinical and contract vocabularies are normalized across all payers. This eliminates the need to manually reconcile and align payer-defined measures and values.

Surface Data Inconsistencies

Inconsistencies between payer data and EHR data are visually highlighted directly in the workflow, allowing the care team to rapidly evaluate payer and EHR data accuracy without having to manually search the patient’s chart.

View All Patient Care Caps

Drill-down into the patient record to view all care gaps and available EHR data, providing additional care gap and clinical content to facilitate efficient, data-driven decision making.

 

Automatically assign patients to health improvement programs for care team action

Conduct Patient Outreach

Auto-populate programs for care coordinators according to risk and condition. Care coordinators can view patients by payer, program, cohort, and risk factor, boosting productivity and accelerating their workflow.

Target Priority Patients and Measures

Display only the priority care gaps that matter most to the practice, focusing care coordinator attention on actions that directly impact patient health and provider payment.

Document Care Team Actions

Create a record of care team actions for each patient and care gap. Automatically document effort and actions if a patient is unresponsive after multiple contact attempts.