Four Questions for Aaron Fulner, Senior Director, Product Marketing, Edifecs, Post-Webinar Interview:

By Claire Thayer, March 8, 2019

Recently, Aaron Fulner, Senior Director, Product Marketing with Edifecs, participated in a Healthcare Web Summit webinar discussion that illustrates how health plans participating in government-sponsored programs, such as Medicare Advantage, can take off the blindfold and improve risk-adjusted revenue accuracy as well as value-based program performance. If you missed this informative webinar presentation, “No More Blindfolds: Improving Value-Based Outcomes and Optimizing Revenue,” we invite you to watch the On-Demand version here.

After the webinar, we interviewed Aaron on four key takeaways from the discussion:

1.  Can you explain the impact on provider satisfaction as a result of this approach?

Aaron Fulner: By enabling a health plan to be more targeted with their requests, and reducing the overall volume of requests, provider abrasion can be reduced.

2. There's a lot of discussion in the industry around A.I. and machine learning.  What are some of the trends in AI that Edifecs is particularly excited about?

Aaron Fulner: In discussions with our partners, we are seeing a lot of industry excitement around the ability to stem the tide of opioid abuse and also the application of AI and ML technologies to more accurately identify targets to prevent disease progression and readmissions, improve patient medication adherence, project value-based care outcomes, improve risk-adjusted revenue integrity and Stars/HEDIS scores.

3. What are some of the challenges of having claims and clinical data in separate siloes?

Aaron Fulner: When plans house claims and clinical data in separate siloes it renders any correlation between the two datasets, at worst, impossible and, at best, unusable or irrelevant given the lag time and the spreadsheet-based process employed by most plans. When this occurs, plans miss out on additional dimensions of data that can be used to improve intervention planning and value-based program performance, not to mention enhanced risk-adjusted revenue integrity.

4. In your Food for Thought discussion, you mentioned importance for good insight into submitted encounter data and how this relates to the risk scores and subsequent reimbursement received back from CMS. Can you elaborate more here?

Aaron Fulner: Without complete visibility into the encounter lifecycle, managed care plans can lose sight of the volume and quality of claims submitted vs encounters submitted. Additionally, especially for managed Medicaid plans operating in states with stringent timeliness and completeness requirement, there can be significant penalties for not meeting those standards. Also, and this paramount, plans can lose sight of exceptions/rejections coming back from CMS for Medicare Advantage. Poor visibility and a lack of prioritized workflows can negatively impact optimal risk scoring and therefore reduce risk-adjusted revenue integrity.