Products and Models

Certilytics’ comprehensive product suite offers solutions to health plans, health system providers and employers as they adapt their business to more highly competitive underwriting, member engagement and payment reformation environments. Certilytics maintains an ongoing research and development effort to provide customers with both standard new releases of products, as well as the capability to design and install customized features to each module. Customers have the option to contract with Certilytics to provide only the Data Services module.

Provider Profiling

As customers take on more risk, Certilytics helps understand predictive health information needed to unlock the combination of treatments and services that can lead to better patient, provider, and economic outcomes for health conditions.

Population Health

Certilytics provides a unique approach that assesses the clinical and behavioral characteristics of individual members rather than the average attributes of a population. Results and accuracy are driven by our deep focus on cleansed and enriched data as well as advanced behavioral science

Financial Forecasting and Risk Underwriting

Certilytics improves understanding of individual patient clinical, behavioral and lifestyle attributes with their contribution to financial results. We’ll create stop-loss modeling and pricing, refined underwriting and actuarial models and determine drivers of ROI from implemented programs.

Payment Integrity

Carewise Health uniquely integrates technology, analytics, nurse auditors and case managers to provide a holistic payment integrity solution. Our analytics leverage the power of the predictive analytics. Our solution spans the point at which we can help a member avoid unnecessary care to the point where the collection of overpayments may be unnecessary.

Provider Profiling

Features

  • Individualized patient methodology with attribution to facility or provider
  • Improve financial and quality results by understanding the most important clinical and lifestyle gaps to close
  • Optimize network by benchmarking providers against peers and reviewing their claim costs, cMeasures, and iScores
  • Measure effectiveness of quality improvement campaigns and provider P4P contracting efforts
  • Establish provider iScore targets as “bonusing” mechanism on the right clinical goals

Commercialized and customized versions are deployed using SaaS/PaaS and fit with PEPM pricing. Our secure infrastructure hosts all software and integrates customer data sets. Customers access their newly assembled, enriched and cleansed data sets. Our Data Services Platform produces a proprietary grid reporting of algorithmic results (proprietary predictions, stratifications and relationships), standard and customized studies and reports, and self-service dashboards.

Population Health

Features

  • Measure and track the unique health, behavioral and lifestyle risks that drive a given population’s medical and pharmacy costs
    • Allows for better selection, design and implementation of clinical, utilization and lifestyle management tools
    • Quantify the clinical and financial impact of different interventions through their resulting effects on iScore, CIGM and cMeasures
  • Focused Solutions include:
    • Risk & Cost Analyses
    • Medical & Pharmacy Claims Utilization Management
    • Third Party Tracking & ROI Measurement
    • Preventive Medicine, Gaps in Care & Actionable Conditions
    • Clinical Outcome Modeling
    • Member Stratification

Financial Forecasting and Risk Underwriting

Features

  • Understanding individual patient clinical, behavioral and lifestyle attributes and their contribution to financial results
  • Stop-Loss Modeling and Pricing
  • Refined Underwriting and Actuarial Models
  • Determine drivers of ROI from implemented programs
  • Modeling is performed at the individual patient, with the ability to calculate risk at any level of aggregation

Payment Integrity

Certilytics’ partnership with Carewise Health uniquely integrates technology, analytics, nurse auditors and case managers to provide a holistic payment integrity solution. Ultimately, our analytics will provide health plans a means to perform “prospective” payment integrity “audits” using the power of the predictive analytics. Our solution spans the point at which we can help a member avoid unnecessary care to the point where the collection of overpayments may be unnecessary.

Health plan customers can now predict and assess risk more accurately and completely to achieve:

  • More valid and consistent audit results and decisions
  • Improved provider network contracting
  • Improved provider relations
  • Increases accuracy of payments
  • More timely audit results to providers
  • Improved identification of potential fraud and abuse

Data Cleansing, Standardization and Enrichment

  • Clean data drastically improves analytics and allows for seamless linking of disparate data sets
  • Use proprietary algorithms verify critical content, such as member IDs, provider numbers, diagnosis codes and procedure codes
  • Gain insight from combining traditional and non-traditional data sets

QEC (Quality, Efficacy, Cost) Analytics

  • Use proprietary, predictive algorithms identify the cases that should be subject to nurse audits or care management
  • Create analytics of provider and member profiles
  • Identify and track high-risk providers
  • Build a road map of improved clinical and financial metrics

Analytics/ ID

Specifically, QEC (Quality, Efficacy, Cost) Analytics, these proprietary, predictive algorithms can be used to achieve various client goals, including:

  • Identify and recover inappropriate claims and overpayments
  • Identify the cases that should be subject to nurse audits or care management
  • Create provider and member profiling
  • Generate a road map to improved clinical and financial metrics
  • Reduce the cost of the payment cycle
  • Avoid and prevent inappropriate claims and overpayments