Payer Gaps in Care

How It Works

Enli’s Payer Gaps in Care solution enables provider organizations to maximize payer incentive revenue by automating patient attribution, prioritizing high-value opportunities, and coordinating care delivery. For every dollar spent on Enli’s Payer Gaps in Care Solution, an estimated return of $10 can be expected.

New or updated contracts are processed, measure-codified, and consolidated so care gaps can be analyzed in aggregate, regardless of naming convention.

Payer member lists are automatically reconciled with EHR records to surface patients with care gaps. Possible matches, documentation issues, or discrepancies in attribution are placed into separate guided reconciliation workflows. Attributed patients with gaps are prioritized based on incentive amount and tier thresholds across contracts, ensuring high-value care opportunities are targeted first.

Once identified and stratified, cohorts flow into Central Worklist, a Best in KLAS care coordination application. Role-based task and decision support is customized for each patient and guide the care team to close gaps though outreach, assessments, and appointment scheduling. A patient-facing mobile care plan gives teams the power to display relevant information for the patient. It also saves staff time by incorporating patient-generated data and actions into the shared workflow.

Report dashboards visualize payer gap performance by contract, or by measure across contracts, and compares current incentive capture with the maximum amount possible across contracts. Performance is also analyzed at the clinic and provider level with respect to addressing and closing payer gaps.

 

Aggregate contracts and identify attributed patients

Contract codification

Codify new contract through a simper interface and adjust measures and parameters when existing contracts are updated. This boosts staff efficiency by reducing the time it takes to process new and existing contracts.

Measure consolidation

Normalize similar measures from different agreements using a common vocabulary, allowing gaps and incentive opportunities to be viewed in aggregate across all contracts. This increases the effectiveness of the care team by focusing effort on care gaps that exist is disparate contracts.

Attribution and reconciliation

Automatically match payer member rosters with EHR patient lists. Reconciliation workflows assist with resolving documentation or attribution inconsistencies. This improves efficiency by completely automating member/patient matching; staff time is only required to reconcile the exceptions, which is a one-time exercise.  Save additional resources by reconciling documentation issues where services where rendered but the payer is not aware. Facilitate onboarding for members attributed by the payer but are not patients in the EHR.

 

Maximize incentive capture

Measure performance analysis

Analyze the status of attributed populations with respect to performance gaps, and automatically prioritize measures and cohorts based on the maximum incentive value. This drives revenue by focusing resources and activities on measures that are prioritized based on the greatest incentive opportunity.

Incentive tier analysis

Assess progress towards incentive tiers that unlock greater reimbursement value. This maximizes potential incentive revenue by focusing on measures where greater incentives are unlocked when a certain percentage of the attributed population is addressed.

Cohort prioritization

Stratify patients across all contracts according to measure performance and incentive tiers so that lists are prioritized for the care team. This increases revenue by focusing the care team on activities with the greatest incentive value.

 

Close care gaps and measure progress

Care gap workflow

Support the care team with prioritized patient and gap-specific workflows that guide outreach, assessments, and scheduling. This helps maximize financial incentives by helping the care team target priority patients first and close gaps efficiently.

Mobile Care Plan

Provide a patient-facing app that extends the care team workflow to the patient, making them a part of the care team. Supply additional health status information, alerts, reminders, and communications. This reduces the burden on the care team by allowing the patient to record data and conduct assessments that flow into the shared care team workflow.

Contract, facility, and provider performance reporting

Analyze measure performance, and clinic or provider efficacy in closing gaps, and identify specific ways to improve outcomes. This help close more gaps by identifying the root causes of variations in care delivery that leave gaps unaddressed.