Healthcare Payer Solutions

With the rise of at-risk members, payers have developed innovative ways to use available medical, pharmacy, and clinical encounter data to gain deeper insight into the member profile. While recognized as highly valuable, clinical lab-testing data aggregated from many sources still presents an operational challenge for payers to harmonize and incorporate data-driven findings into the member profile.

Prognos has leveraged its deep experience with clinical lab data to create healthcare payer solutions that empower payers with a timely and comprehensive view of their membership. Bringing together cross-payer, historical, and current lab data from multiple sources, Prognos’s platform, prognosFACTOR™, harmonizes the available data and applies machine-learning techniques to give payers the insight they need to better support and manage their membership.

Healthcare Payer Solutions that Impact Clinical and Financial Outcomes

Clinical lab test results can be leveraged to improve the performance of underwriting, care management, social determinants of health (SDOH) initiatives, quality management, prospective and retrospective risk adjustment, as well as value-based care programs. With Prognos, you can can readily access historical and current clinical lab results of members to gain a retrospective and predictive view of your members.

Clinical Lab Results Enhance Member Insight

Payers are leveraging more data sources including medical and pharmacy claims, tele-monitoring, electronic health records (EHR), self-reported data, and other sources of real-world data (RWD) into their programs. With Prognos, harmonized lab-testing insights can enhance these sources of RWD and add significant value in a number of ways:

  • More clinical conditions and co-morbidities can be identified compared to using medical-claims data alone
  • New or previously undetected patient diagnoses can be identified 
  • Longitudinal analyses can be utilized to predict disease prevalence and trajectory
  • Many more data-driven insights can be developed for members, compared to the use of medical-claims data alone 

With Prognos advanced analytics and access to broad, deep and aggregated clinical lab-testing data from multiple sources, payers have the insight to:

  • Identify the right members who would benefit from targeted care and quality programs
  • Manage risk-adjusted membership
  • Empower value-based care initiatives
  • Achieve more accurate underwriting

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More Lab Records than Existing Feeds

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More HCCs for New Member

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HCCs to Claims Suspecting

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Additional HEDIS Automatically Closed Gaps

Why Prognos? 

Most health plans have partnered with one or more national laboratories and may have relationships with regional and hospital labs, as well. However, each lab presents its data differently, resulting in aggregated clinical data that is disorganized, incomplete, and cumbersome to interpret and operationalize.  As a result, health plans may only have access to lab data related to just 20-30% of their membership. 

Unlike data aggregators that provide traditional patient-related healthcare data from such sources as medical claims, unstructured lab data, and prescribing data, Prognos is the only company that is able to provide actionable, data-driven clinical insights that are based on continuously aggregated lab-testing data from a broad (and growing) list of national, regional, hospital, and premier educational institutions. We harmonize, normalize, enrich, interpret, and analyze clinical information – powered by AI and machine learning techniques to yield timely insights. This allows plans to develop and deliver earlier interventions, helping members to achieve better outcomes while managing and mitigating their own clinical and financial risk.

“We chose Prognos because their lab data solutions deliver timely insight, is often used to diagnose medical conditions, and can add significant value for ongoing risk adjustment efforts. We wanted accurate HCC suspects for the optimal impact and lab data is an important component.”

Dean Ratzlaff, Actuarial Director
Optima Health

The Largest Lab Network in the U.S. 

Our clinical lab-testing database includes continuously aggregated lab-testing data from national, regional, hospital, and premier educational institutions.