Innovative healthcare AI solution uses diagnostics data to address payer challenges around risk adjustment, clinical quality and care management

NEW YORK, NY–(Marketwired – April 27, 2017) – Prognos, an innovator in applying artificial intelligence (AI) to clinical diagnostics, will deliver a presentation on improving risk adjustment and quality reporting with clinical lab results at the 14th Annual World Health Care Congress, April 30 – May 3, 2017 in Washington, DC.

Payer organizations will learn about how comprehensive lab data analytics can augment their current approaches to risk adjustment, clinical quality and care management. Three main benefits include the following:

  • getting early clinical insights into health risks for existing and newly enrolled members;
  • early identification of health issues, including chronic diseases such as diabetes, to support interventions and lower medical costs; and
  • More comprehensive identification of patients’ chronic conditions for HEDIS and Star reporting metrics to improve quality outcomes and star ratings.

“Payers increasingly seek clinical data sources that can enable proactive care management, and lab results is one new source that is getting traction. Lab data influences 70% of medical decisions and is available almost immediately,” said Bob Maluso, VP, Business Development, Prognos. “When Prognos interprets lab data through AI and advanced analytics, it can identify what patient trajectories look like and compare them to historical data to predict where these patients are at in their disease.”

Unlike claims that can take weeks or months to process, diagnostics test results are available in near real-time. They also provide unrivaled level of specificity for clinical conditions. When integrated into insurers’ claims-based programs, diagnostics data enables earlier and more comprehensive and accurate clinical insights to benefit care management of both existing and new members. Specifically,

  • For existing members, the detailed results uncover needs that may have been overlooked just based on a claims analysis.
  • For new enrollees, the rich clinical insights enable the health plan to get members into the appropriate care/disease management programs from day one. Notably, this includes enhanced management of newly enrolled patients across the ACA exchange, Medicaid and Medicare.

“We currently estimate that about 10-15% of conditions are never discovered from claims alone, and claims also underreport condition severity by 30%. High-quality lab data not only fills that gap but does it quickly, enabling payers to deliver personalized interventions earlier in the disease process,” said Maluso.

Once diagnostics data is incorporated into the payer’s process, insurers can expect reduced medical expenses, optimized risk-adjustment reimbursements and optimal clinical quality outcomes. Importantly, these benefits translate into benefits to customers as well. With higher reimbursements via risk adjustment, payers can invest more to ensure patients can get better care and prevent negative progress of disease as well as support patients with higher health risks.

Health Plan & Payer Summit attendees are invited to come to the Prognos presentation on Tuesday, May 2, at 10:30 am EDT. To learn more about how Prognos helps payers solve risk adjustment challenges, visit our healthcare payer solutions webpage.

About Prognos

Prognos is an innovative healthcare AI company focused on eradicating disease by driving decisions earlier in healthcare in collaboration with payers, Life Sciences and diagnostics companies. It is the only company specializing in applying healthcare AI to clinical diagnostics. The Prognos Registry is the largest source of clinical diagnostics information in 35 disease areas, with over 8 B medical records for 150M patients. Prognos has 500+ extensive proprietary and learning clinical algorithms to enable earlier patient identification for enhanced treatment decision-making, risk management and quality improvement. The company is supported by a $23M investment from Safeguard Scientifics, Inc. and Merck Global Health Innovation Fund (GHIF). For more information, visit

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