Risk Adjustment & Quality Analytics

Realize more value with clinically based solutions.

Identify members with lab values linked to risk adjustable diagnoses and to quality measure compliance.

Payers rely upon complete and accurate diagnosis coding of disease burden to ensure that they receive appropriate funding in the form of premium, to cover healthcare and administrative expenses of their insured populations. Additionally, payers are held to an objective set of quality performance measures that allow consumers to make informed decisions with respect to procuring quality and cost-effective health insurance.

Timely access to laboratory data greatly increases insight into the level of disease burden of insured populations and the quality of care being delivered to that population.

Clinical depth across 300M+ US lives
Risk Adjustment & Quality Measurement.

Laboratory values are indicative of the presence of greater than 3,000 risk adjustable diagnoses that map to 25 hierarchical condition categories (HCCs).

They also are directly tied to many quality measures, to include those for:

  • Diabetes Care
  • Cervical and Colo-rectal Cancer Screening
  • Pediatric & Adolescent Lead Screening
  • Chlamydia Screening

A single unified lab data extract
Enhance member insight.

To gain insight into the laboratory values of their membership, payers must integrate laboratory data from a variety of data sources, in a variety of data formats, with little to no standardization.

Prognos Health solves this problem by providing payers with a single unified data extract of all of the available laboratory values for their entire member population. Prognos obtains laboratory from national reference labs, regional and local laboratories, Health Information Exchanges (HIEs), clinical information systems and other data sources. The lab data is then normalized. Harmonized, AI enabled clinical algorithms are applied and it is then converted into an easily integrated data extract. This data extract can be:

  • all available laboratory values
  • values linked to specific risk adjustable diagnoses
  • quality measures, or disease states

Easy to operationalize
Integrate seamlessly with existing workflows.

The Prognos harmonized laboratory data  solutions integrate seamlessly with existing workflows and programs, using analysis of lab-based testing data to identify new or previously undetected disease burden, for both retrospective and prospective review. Payers incorporate the new data-driven insights identified by enriched clinical lab data into workflows, and use them to prioritize risk adjustment, quality measurement and disease management initiatives. This data can drive chart retrievals and in-home assessments, and prospective member encounter initiatives.

Lower operational costs associated with chart retrievals, home visits and unnecessary member engagement. 

  • Identify chronic disease in a more timely manner and reduce false positives for more targeted and effective member outreach or chart retrieval and review
  • Equip operations teams with access to more complete member profiles to inform their efforts

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

From member pre-enrollment to post enrollment.

Leverage harmonized lab data to drive better results 

  • Identify members who are likely to have risk adjustable diagnoses based on an analysis of their historical clinical data
  • Continuously monitor members with risk adjustable diagnoses for new clinical data impacting risk scores
  • Obtain laboratory results required to demonstrate compliance with quality measures
  • Continuously monitor member populations for new laboratory values impacting compliance with quality measures

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