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A healthcare payer’s journey to unify member data, drive analytics, and improve care delivery

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Background

A large health plan turned to Verato for its EMPI solution to create a Universal Member View (UMV), a centralized hub of demographic data driving critical systems like their Enterprise Data Warehouse and Medical Management System. The plan faced challenges with their previous identity matching solution, which only achieved 75-85% accuracy, leading to care gaps and manual work.

By implementing Verato, identity matching accuracy skyrocketed to 98%, resolving data inconsistencies and empowering over 75,000 case managers and nurses with a unified view of each member. This transformation improved care delivery and operational efficiency, driving better outcomes across Medicaid, Medicare, and private managed care members.

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12% matching uplift for supplemental data

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Identity matching improved from 85% to 98%

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90% increase in member satisfaction surveys

Challenge

Unmatched identities lead to care gaps, reporting issues and manual work

The health plan receives continuous supplemental and EHR data feeds, requiring a centralized view of member records to support downstream systems and workflows, including their enterprise data warehouse. This warehouse powers risk and quality analytics, as well as HEDIS gap closure.

To modernize medical management and reduce manual effort, the company developed a cloud-based application that provides a comprehensive view of each member, accessible by case managers, nurses, and disease management teams before member engagement. The cloud system improved data consistency and resolved replication issues.

However, the plan’s rules-based matching algorithm (not Verato) limited identity matching accuracy to 75-85%, leading to care gaps, reporting issues, and manual work to resolve unmatched identities.

“Verato helps us manage these scenarios so we can compile that true longitudinal view, leverage the data accurately, and have accurate calculations at the end of the day. With the data, we can understand fully what is happening within our populations and take the appropriate workflows and actions to manage those populations appropriately."

Sr. Director of HEDIS

Solution

Unifying member data to drive analytics and improve care

The member journey is crucial for both the health plan and the members, who expect seamless access to their data, regardless of the system it’s stored in. This health plan conducted a survey to gather member experience feedback by region and further analyzed activities over the past year to assess:

  • Regional experience based on claim adjudication delays,
  • Specialty care access issues,
  • Proximity to call centers,
  • PCP visit frequency, and
  • Readmission rates.

Using Verato, the health plan now unifies member data across systems with a common identifier, enabling advanced analytics to drive improved care experiences and inform strategic business decisions.

Results

Ensuring nurses can address needs in a timely manner

Single Member Profile: A member can have 3 or more different records within their profile at any given time if they are enrolled in 3 different lines of business.  Today, searching for a single member presents data to satisfy the mandated set of requirements that need to be completed and recorded for each line of business.

Matching clinical data to the right member: To ensure a complete and accurate member view, the organization decided to step away from the use of their own matching systems and fully look to Verato to improve their member matching .

Care Giver Efficiency: Today, the system has 10s of thousands of nurses managing their member’s health for ALL lines of business, like a mobile health coach program. For a Medicaid member requiring an in-home assessment to address activities of daily living, potential clinical needs, or social services referrals within 90 days of enrollment, users view all records in one profile.

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