Health Plans and Payers

Risk Adjustment & Quality Management

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Get Help with Risk Adjustment & Quality Management

Veradigm provides complete transparency into the efficacy of your Risk Adjustment, Quality Management, and Pharmacy Programs. Our solutions are geared for Health Plans and At-Risk Providers.

Veradigm’s vast array of products can address the needs of a number of functional areas, ranging from Finance, Actuary, Risk Adjustment to Quality, Network Management, and Pharmacy Program Management.

Our Payer Solutions Can Help You:

  • Close gaps and enhance financial performance
  • Improve risk and quality scores
  • Deploy the right intervention, with the right provider, at the right time

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Payer Products

  • Risk Adjustment Analytics & Report: Calcul8
  • Quality Analytics: Qualit8
  • Value Based Arrangements: Evalu8
  • Risk Mitigation: Valid8
  • Provider Engagement: Collabor8
  • EMR Analytics & Integration: Integr8
  • Coding Technology: Popul8
  • Submissions & Reconciliation: Reconcili8

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Risk Adjustment Analytics & Reporting | Calcul8 Our solution that helps plans avoid administrative waste, optimize risk-adjusted revenue, and dynamically deploy intervention initiatives

  • Delivers advanced risk adjustment analytics to the ACA Commercial, Medicare Advantage, and Managed Medicaid Markets as well as Value-Based Payment Models for Medicare
  • Provides the real-time visibility needed to monitor and manage risk adjustment revenue against budgeted gap closures and Key Performance Indicators (KPIs).
  • Directs intervention initiatives based on patent pending Dynamic Intervention Planning

Learn More About Our Risk Adjustment Analytics & Reporting Solutions


Quality Analytics | Qualit8 Uses predictive analytics and Dynamic Intervention Planning to prioritize gap closure efforts for Quality Rating Systems, Star Ratings, and Medicaid

  • An NCQA Certified HEDIS engine to help close quality gaps and improve quality scores
  • Advanced analytics for monitoring, measuring, and reporting on each quality metric, and assimilating these data in order to redirect interventions where needed most
  • Uses a robust series of analytics dashboards to help health plans deploy impactful Quality Management programs

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Value-Based Solutions | Evalu8 Empowers payers and participating healthcare providers with analytics and insights to optimize their value-based programs

  • Produce visibility into the metrics to monitor performance of value-based contracts and arrangements
  • Assess the on-going performance of programs
  • Leverage common metrics to ensure alignment across the contracts Identify services that are being performed outside the contract

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Risk Mitigation | Valid8 Assists health plans guard against the financial consequences of a RADV Audit

  • Quantifies and identifies the healthcare providers and conditions that are putting the plan at risk of an audit
  • Deep analytics uncover actionable tactics that can be deployed for research, correction, and provider education
  • Enabled for both HHS RADV and Medicare RADV Audits

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Provider Engagement | Collabor8 Provider engagement solution that engages healthcare providers in an efficient and respectful manner while reducing administrative burden and driving efficiencies

  • Leverages patent-pending Dynamic Intervention Planning to identify the right intervention with the right provider at the right time
  • Provider alerts supported by Member Clinical Profiles
  • Facilitates bi-directional communication between participating healthcare providers and the gap analytic process

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EMR Integration | Integr8 Enables the automated exchange of medical charts and facilities payer/provider collaboration

  • Eliminates the need for more costly and labor-intensive means of data collection by automating the extraction of CCDA/medical record information
  • Rather than sending faxes or requiring medical office staff to log into another portal, embeds analytics and alerts into the provider’s workflow
  • Enables better care coordination and faster turnaround times to improve closure rates for coding, documentation, and quality gaps

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Coding Technology | Popul8 Leverages advanced technologies to produce an accurate and efficient means for identifying, documenting, and coding members’ conditions

  • Uses Machine Learning, Natural Language Processing (NLP), and Optical Character Recognition (OCR) to identify, validate, and prepare for efficient and accurate submission
  • Optimizes coding workflows to manage both structured and unstructured data
  • Features an intuitive interface with intelligent audit capability and error-proofing

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Submissions & Reconciliation | Reconcili8 Scalable, flexible, integrated solution to help ensure timely, accurate, and complete EDPS/RAPS and EDGE Server Submissions

  • Complete and accurate tracking and status-monitoring of all encounters with end-to-end visibility into member claims data
  • Workflows configurable for batch corrections, reviews and approvals, and re-submissions to enhance workforce efficiency
  • Integration with our industry-leading trading platform to enable seamless EDI channel connectivity

Learn More About Our Submissions & Reconciliation Solutions



Government Programs

Veradigm services all market for risk-adjustment government programs

  • ACA: ACA Commercial / Qualified Health Plans (QHPs)
  • MA: Medicare Advantage
  • MEDICAID: Managed Medicaid
  • DUALS: Dual Eligible
  • SNP: Medicare Special Needs Plans (SNP)
  • PCMH: Patient-Centered Medical Homes (PCMH)
  • ACO: Accountable Care Organizations (ACO)
  • MACRA: Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)

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