Executives at health plans including Medicare Advantage (MA) and Medicaid managed care organizations (MCOs) partner with ReferWell to tackle value-based care initiatives for their highest risk, costliest members and help the rest of their members stay healthier. ReferWell provides technology and operational support to close care gaps with less effort. With easily shared clinical data, payers can feel confident that physicians will direct care transitions to the highest quality, lowest cost network providers. And that their members will enjoy a better experience.
Challenges Solved for Health Plans
Drive Care Transitions to the Optimal In-Network Providers
We curate a complete list of your plan's top-tier, highest-quality/lowest-cost specialists so network providers direct members to the appropriate option, personalized to each member's needs and your organization's value-based goals. Filter referral providers by insurance accepted, subspecialty, responsiveness, location and language.
Get Members to Follow Through on Appointments More Often
ReferWell enables referral appointment scheduling at the point-of-care and our care navigators book preventive/care gap appointments at the point of call; the system provides automated reminders, including automated satisfaction follow-up surveys. We're helping plans increase member compliance with recommended care by 60–110% across all beneficiaries as they improve the member experience. More referrals get seen. More care gaps get filled. More HRAs get done.
Track & Improve Care Coordination
No more chart chasing! With complete network visibility, track that members completed their appointments and capture the results for the member’s PCP by closing the loop.
Improve the Member Experience
When you take the burden of finding care off of members, you boost satisfaction and retention rates. That translates to higher Star ratings, CAHPS and HEDIS scores and CMS reimbursement.
“ReferWell is super easy to use and having patients' insurance information and medical records ahead of time makes the whole provider network much more efficient.”
– Head of Provider Networks, large payer
Start closing care gaps today.
See how one health center increased its colorectal cancer (CRC) care gap measure by more than 80%. Fill out the form to download your case study and learn how ReferWell’s care navigators schedule appointments for gaps in care.
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Explore Solutions for Health Plans
About Medicare Advantage
Medicare Advantage, also called Medicare Part C, is a health insurance option available to people who are eligible for Medicare (generally those ages 65+). Private insurance companies, or Medicare Advantage organizations, provide these plan options directly to beneficiaries, whereas the Centers for Medicare & Medicaid Services, an agency of the federal government, administers Original Medicare.
About Medicaid Managed Care Organizations
Each US state designs its own Medicaid program in accordance with federal rules. Most states use private health insurance plans known as Medicaid managed care organizations (MCOs) to deliver comprehensive health care to Medicaid beneficiaries on behalf of the state. Those who qualify for Medicaid include low-income individuals, certain pregnant women and children and others as determined by the state.
Like Medicare Advantage plans and accountable care organizations, MCOs accept a set (capitated) per member per month payment for the services they provide and are therefore incentivized to provide the most efficient, highest quality care at the lowest cost.
Quality Matters: Plans Focus on Star Ratings, CAHPS and HEDIS
Under CMS Star Ratings, plans need to achieve four or more stars to receive a five percent bonus payment. Starting this year, the patient experience, access to care and member complaints category are starting to shift from a weight of one to four over the next three years.
The CAHPS Health Plan Survey — the AHRQ’s measure of member experience — asks members to rate their experience with communication and access to care.
HEDIS, the NCQA’s measure of plan performance, looks at utilization, outcomes, access, experience and more.
What do all three of these measurements have in common? They require plans to be laser focused on member satisfaction, providing a positive member experience with accessible, high-quality care in order to drive the highest reimbursements and revenue.
What is HCC Coding and Why Does it Matter?
Hierarchical Condition Category (HCC) coding is a risk-adjustment model that attempts to estimate the future health care costs of members; it is the model used by CMS to determine risk adjustment payments to health plans.
With accurate HCC coding, plans can target their highest-risk members and most complex cases for the appropriate level of care that will improve health outcomes. Health care technology offers payers the ability to increase network visibility to collect HCC coding, identify high-risk members and efficiently improve their overall health.
The Medicare Advantage Landscape in 2021
The US Department of Health and Human Services (HHS) Office of Inspector General (OIG) recently expressed concerns about MA plans that generated about $2.6 bil. in revenue from filing Health Risk Assessments (HRAs) without providing further member care. The Office was particularly concerned about in-home HRAs, which accounted for 80% of total HRA claims; these are unlikely to have been provided by the beneficiaries’ primary care providers (PCPs), as is the preference.
Then, CMS announced that starting in 2022 the agency will exclusively use encounter data to determine the member's risk score. The change makes it increasingly critical to boost patient show rate and capture the encounter data — whether care happens at home, in the office or virtually.
In essence, the agency wants to ensure that payers follow-up on HRAs with ongoing care for their sickest members. Plans need to think about how they improve care coordination for their beneficiaries — managing care transitions efficiently and identifying and providing care for their highest-risk members. It’s now time for MA plans to focus on solutions to improve care management efficiently if they are going to maintain and grow their revenue.