Closing Member Care Gaps Remains Paramount

When we see or hear the term “care gaps” our thoughts turn first to health plan members. What is standing between them and the care they need? What can providers, employers, and health plans do to close these gaps?

One answer is to extend more member health services into the members’ homes. “Healthcare to the home” is more than a goal or a motto. Parts of it are already in place, and more is coming faster than we imagined even a year ago.

For example, digital health applications, telemedicine services, and remote monitoring devices were all growth industries before the COVID-19 Public Health Emergency (PHE) increased the need for them. In response, providers are using PHE-enabled telehealth reimbursement opportunities to increase member reach to rural areas and to other under-served populations. This is one way that health plans and providers reduce member care gaps.

But member care gaps are not the only gaps that health plans and providers must contend with. There is another kind of care gap, one that affects providers directly and everyone else as a consequence.


Providers Face Care Gaps of Their Own

Finding and solving member care gaps is a mission so important that addressing provider care gaps can get lost in its shadow. We can see a provider care gap as the gap between providing the best member care delivery experience and remaining profitable in a rapidly changing delivery, regulatory, and competitive environment.

Health plans can, in partnership with productivity-enhancing automation and artificial intelligence software, help fill this gap.

Of course, health plans already know and respond to the need for provider support. Many plans provide provider-specific online resources, such as eligibility and claims status checking, training programs, and administrative tools like forms, guides, and policies. But these are no longer enough. The end of the PHE is becoming more foreseeable as vaccinations increase. When that happens, providers must have a way to keep meeting member demand for more home health delivery. They must accomplish this despite less generous reimbursement codes, reduced insurer coverage, and increasing competition from telemedicine vendors with their own physician networks.


Closing Provider Care Gaps Through Targeted Hybrid Care

During the PHE health plans and providers successfully collaborated to meet a demand spike for telehealth services. With this experience behind us, offering more member home-based health services is not the challenge for providers that it was a year ago. The issue now – and in the future – is more than supply-and-demand. It is one of squeezing the utmost from provider clinical and administrative efficiencies.

Health plans can’t do much more to increase cost efficiency by negotiating shared savings frameworks, narrow network or bundled payment models, or other contract strategies. In addition, developing their own internal health services, such as telemedicine, can be a costly and time-consuming task for plans to take on their own.

Instead, the new approach to closing provider care delivery gaps for is another reflection of what is emerging in the wake of the PHE: hybrid care, in which health plans, providers, insurers, employers and vendors deliver healthcare that seeks out and closes gaps wherever they are found.

In our present competitive provider marketplace with its thin profit margins, no revenue-enhancing or cost-saving avenue should remain unexplored. Maximizing HEDIS scores and better compliance with HHS-RADV audits can be daunting, but can play an important role in helping providers fill patient care gaps. Providers and health plans get optimal support by using Reveleer’s efficiency-boosting software solutions: customizable, scalable, deep learning software that maximizes return from risk adjustment, enhances quality improvement programs, and simplifies audit compliance.

Request a demo and get your questions answered by one of our Risk Adjustment and Quality Improvement experts today.

About The Author

Reveleer is a healthcare-focused, technology-driven workflow, data, and analytics company that uses natural language processing (NLP) and artificial intelligence (AI) to empower health plans and risk-bearing providers with control over their Quality Improvement, Risk Adjustment, and Member Management programs. With one transformative solution, the Reveleer platform allows plans to independently execute and manage every aspect of enrollment, provider outreach, data retrieval, coding, abstraction, reporting, and submissions. Leveraging proprietary technology, robust data sets, and subject matter expertise, Reveleer provides complete record retrieval and review services, so health plans can confidently plan and execute programs that deliver more value and improved outcomes. To learn more about Reveleer, please visit