Payers strategically develop networks that align with market needs, maximize reimbursement, and cater to the preferences of members and providers. After providers and members are enrolled in a plan, payers must monitor utilization, process claims, and manage overall plan performance. Payers and individual plans have incentives to steer members towards in-network services, leveraging negotiated contractual rates to ensure more predictable medical costs and care management. Effective network performance enables payers to manage costs, support care coordination, and strategically enhance the network of providers and service coverage over time.
The Clearsense Approach
Clearsense’s approach quickly establishes visual groupings and indicators for cost and utilization patterns that inform actionable insights. Clearsense aggregates core payer data sources, including claims and rosters. We offer accelerators that expedite data mapping to our analytic models, resulting in the swift production of visualizations. By collaborating with payers, Clearsense helps define in-network and out-of-network providers and services and define specific cohorts for in-depth analysis.
How Clearsense Helps
- Producing intuitive visualizations of the member journey that readily identifies trends in cost and utilization.
Comparing allowed, charged, and paid amounts to assess provider cost and target providers for network inclusion and contractual adjustments.
Accurately attributing members to providers.
Identifying providers, visits, and services likely to result in out-of-network utilization and member leakage.
Aggregating member and provider data from diverse sources to inform analytics and enable drill-down views of network performance, providers, members, and utilization.
Why Payers and Payviders Choose Clearsense
Facilitating the seamless and transparent exchange of information between healthcare providers and payers in compliance with NCQA DAV certification.
HL7 and FHIR-enabled platform supporting common healthcare messages and transaction types, including CCD, ADT messages, and claims, following healthcare standards, including USCDI and EDI X12.
Velocity and Agility
Leveraging the Clearsense Healthcare Data Model, 1Clearsense scales to accommodate your organizational growth and rapidly responds to market demands with unmatched velocity.