Payer Provider Accountability Consulting

Points of Light 2022: Recognizing Successful Payer/Provider Collaborations Report Cover Image

Case Study

Points of Light 2022: Recognizing Successful Payer/Provider Collaborations

05 May 22 | Boyd Stewart and Lois Krotz

Despite their common goal of enabling efficient, effective healthcare, payer and provider organizations often find themselves at odds, struggling to navigate the intersections where disparate processes and systems converge. The goal of KLAS’ new Payer/Provider Initiative is to help reduce this friction by facilitating trust, collaboration, and alignment between payers, providers, and HIT vendors. As part of the initiative, the annual Points of Light awards celebrate success stories—or “points of light”—from payers, providers, and vendors who have partnered together to reduce costs and inefficiencies and improve the patient experience. 14 such collaborations were awarded a 2022 Points of Light award, and their strategies and outcomes are shared in this report to illustrate the art of the possible. The report’s Executive Overview provides a high-level summary of the types of challenges tackled and the outcomes achieved, while the full report provides an in-depth case study of each collaboration. See page 6 for the full list of winners.

Negative social and environmental factors, such as unsafe housing or food insecurity, can worsen patient health and lead to them overusing the emergency department (ED). In this collaboration, Sentara Health engaged N1 Health to identify social determinants of health (SDOH) for Medicare and Medicaid members and match these individuals with benefits to facilitate better care and promote re-enrollment. The partners also used AI to determine which patients had high risk for housing insecurity so that they could provide housing assistance via a grant-funded program. These efforts lead to reduced ED usage, increased use of preventive services, and higher re-enrollment in Medicare/Medicaid.

Due to changes in the health plan market, Cigna Healthcare’s membership unexpectedly increased from 350,000 members to 1 million members. In order to ensure appropriate care and reimbursement, the payer organization had to quickly assess, engage, and offer care options to these new members. Cigna worked with MDLIVE and N1 Health to proactively reach out to members with a help-first approach and schedule annual wellness visits for them, ensuring that the members received the right care and that the payer organization was properly reimbursed.

Hierarchical Condition Category (HCC) coding plays an integral role in assessing patients’ risk scores and contributes to quality patient care and appropriate reimbursements. However, provider organizations don’t always have the needed information or training to be able to accurately complete HCC coding and close coding gaps. The stakeholders in this collaboration worked together to seamlessly transfer payer information into clinician workflows, leading to improved data transparency and, ultimately, more accurate coding.

K2 Collaborative - Payer Provider Accountability Consulting

K2 Collaborative - Payer Provider Accountability Consulting

What Is the K2 Collaborative (formerly Payer/Provider Initiative)?

K2 Collaborative - Payer Provider Accountability Consulting

K2 Collaborative - Payer Provider Accountability Consulting

What Is the K2 Collaborative (formerly Payer/Provider Initiative)?

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