Bright Health Risk Overview

Inovalon Overview

InovalonOverview

Client Examples

SolutionComponents

Existing Relationship

Existing Relationship

Bright Health

Brand New Day

• QSI-XL® - Service Bureau Implementation
• Inovalon Medical Record Review (MRR) Services
• Data Visualization and Reporting (INDICES®)
• Quality Improvement: Monthly analytics, MMDM and Point-of-Care Testing
• Risk Adjustment: Retrospective and Prospective
• EDGE Server Submissions

• De-Novo Account: Effective 10/1/2020 (Implementation in progress)
• QSI-XL®- Service Bureau Implementation
• Using internally-built MRR tools for MY 2020; then, Plan will switch to QSHR™ for next HEDIS® season
• Data Visualization and Reporting (INDICES®)

info

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Health Economics & Outcomes Research

Optimal Treatment Protocols

Outcomes-BasedContracting

Life Sciences

Commercialization Strategies

MarketAccess

Payer Operations

Quality ofCare

PatientOutcomes

Clinical OperationalEfficiency

Provider

Providingcloud-basedtools that empower data-driven healthcare

ProviderEngagement

AdministrativeImprovement

Point-of-CareAnalytics

Operational Transparency

PatientOutcomes

PatientEngagement

Payer

Risk Score Accuracy

Clinical Quality Metrics

Financial Performance

Automate Referrals

Medical Claims Processing

Improve Patient Care

Pharmacy

Streamline Order Workflow

Reduce Operational Costs

Patient Outcomes

Empowering Data-Driven Healthcare In Scale

The reach of Inovalon’s platform has grown to touch the vast majority of the United States, able to empower the market’s largest data-driven healthcare initiatives.

100s

Health Plans, Providers, Life Sciences, Pharmacy & Diagnostics Organizations

319M+

(count does not yet include data from ABILITY)

100,000,000+

Patients*

76K+

The MORE2 Registry medical events incidents

Connected Provider Client Sites

Inovalon Headquarters

Provider Sites

Office/Data Center

Hawaii

Puerto Rico

Alaska

Inovalon ONETM Platform Components

ADVANCEDANALYTICS

RESULTS DELIVERED

ENGAGEMENT & OUTREACH

CLAIMS SUBMISSION

MEDICAL RECORD REVIEW

ePASS® EMPOWERED POINT OF CARE INTERVENTIONS

DATA INTEGRATION

Collection & Interoperability

MA & ACAExperience

ProviderEncounter

InterventionMetrics

Retail ClinicAssessment

Member

Security

Targeting

Abstraction& NLP

Provider

Compliance

Virtual Health Visit

Quality Improvement

In-HomeAssessment

Audit Support

Reporting

Incentives

Differentiators

Client Examples

Benefits

Benefits

Benefits

Integrating Quality

Data Lake

Seamless Data Integration

Inovalon’s approach begins with sophisticated data integration tools combined with industry-leading expertise. Our decades of experience means that we understand the unique nuances of healthcare data. Our proprietary data ingestion engine, iPORT-HD™ runs more than 1,100 data integrity checks to ensure that data is complete and accurate – before running analytics.

DATA INTEGRATION

Client Data Provision & Authorized Interconnectivity Data Access

Security

Data Integration & Processing (iPORT-HD™)

Compliance

Mapping of Client Data Elements

• Member/Patient Demographics
• Medical Record Documentation
• OR, Inpatient, & ER Records
• Electronic Health Record

• Health Risk Assessment
• Practitioner Profile
• Eligibility & Enrollment
• Encounter & Procedural

• Pharmacy
• Imaging Report
• Laboratory & Pathology
• Durable Medical Equipment

• Self-Reporting
• Social History
• ADL
• Cost & Benefits

Data Lake

Staging & Indexing of Raw Data Files

Application of Pre-Load Data Integrity Checks

Application of Mapping & Translation Algorithms

Application of Post-Mapping Data Integrity Checks

Production Data Warehouse Load

Inbound File Transmission Monitoring

Defense In-Depth Security

Inovalon employs a multi-disciplinary approach towards data security:

• Single-sign on and user management portal capabilities
• Hardware and software technologies securing data at rest and data in motion
• Security validation (internal and external penetration testing/assessment), and security industry experts
• Focus on security awareness and posture with people across the enterprise

DATA INTEGRATION

Adaptive security appliances, firewalls, routers, and switches, demilitarized zones, data loss prevention, ID management, traffic & web content filters, network based Intrusion Prevention System (IPS), network penetration testing, behavioral analytics, Security Operation Center monitoring.

Security

Antivirus software, data loss prevention, patching, vulnerability scanning, security baseline specifications for systems, advanced malware protection, hardening

Compliance

Static code analysis, threat modeling, secure coding, penetration testing, security specifications

Data Lake

File and data encryption, enterprise rights management, email security, privilege access management, encryption key management

Corporate security, multi-factor authentication, video surveillance, badges, proximity cards, roving guards

Regulatory and Compliance

Policy, regulatory compliance, extensive data governance and security infrastructure

Inovalon's solutions and subject matter experts partner with health plans, ensuring accurate HCC & Quality submissions which mitigate RADV and other Audit risk by allowing health plans to avoid regulatory diciplinary action and correct processes.

DATA INTEGRATION

RADV compliant documentation and medical record coding

Security

Compliance

End-to-end submissions solution and subject matter experts partner to ensure accurate and complete submissions

Data Lake

Never missed a regulatory deadline

DATA INTEGRATION

Security

Compliance

Data Lake

INDICES 3.0

Use Cases

Risk Score Accuracy Analytics

Inovalon’s risk score accuracy analytics identify diagnoses that may exist, which have been incompletely or improperly reflected within claims data systems and abstracted medical record review to identify reimbursement improvement opportunities.

Un-coded conditions that have yet to be coded in the appropriate DOS and chronic conditions that require coding to a greater level of specificity

ADVANCEDANALYTICS

59%

Medicare

Suspected conditions based on clinical evidence that a member’s condition or disease burden has progressed

Targeting

41%

Max CEDI Score

Quality Improvement

Over-coded chronic conditions that are susceptible to compliance audit or appear to be undocumented in the underlying medical record

True Positive Prevalence

15%

Differentiators

Retail / Commercial

85%

Un-coded Chronic Conditions

Suspected Conditions

Member Group (by cumulative CEDI value; highest to lowest

Predictive Analytics | Intervention Strategy

Based on a member's unique profile and available intervention resources, a member-specific intervention strategy is created. Intervention targeting takes into account several factors including historical compliance, member's past engagement with physician, and likelihood of becoming compliant.

Intervention Modality Priority Score

MemberPriority Score

Measure Priority Score

Compliance (Measure Specific)

Suspected Quality & Risk Gaps

Physician Visit

IHA

PV

ADVANCEDANALYTICS

12

78

SometimesCompliant

77

Somewhat Frequent

75

18 risk gaps including medication adherence gaps

71

Sierra

HighlyFrequent

Habitually Non-Compliant

13 risk gaps including SNP measure gaps

37

24

12

20

65

Targeting

Mark

92

85

HabituallyCompliant

55

Somewhat Frequent

65

23

11 risk gaps

Mary

Quality Improvement

JAN

MAR

FEB

APR

MAY

JUN

JUL

AUG

SEP

OCT

NOV

DEC

PV

Differentiators

Sierra

PV

PV

Mark

IHA

Mary

T: Telephonic; IHA: In-Home Assessment; PV: Physician Visit; SNP: Special Needs Plan; BP: Blood Pressure

Targeting Examples

Quality Improvement Analytics Approach

With industry-leading descriptive, predictive and prescriptive analytic capabilities, Inovalon’s quality improvement solution empowers organizations to identify member-measure clinical gaps and build the optimal strategy to address and close those gaps.

Prescriptive

Predictive

Descriptive

ADVANCEDANALYTICS

• Measure specifications
• Unaddressed member gaps
• Relevant member gaps
• Value of gap resolution relative to plan performance
• Member’s historical behavior—are gaps likely to close themselves (auto-resolution)

• Strength of the member/provider relationship
• Potential impact of member demographics on measure inclusion and compliance
• Data markers that suggest member inclusion
• Necessary compliance conversions
• Cross-initiative gaps

• Provider most likely to close identified gaps
• Appropriate channel, message and appointment setting
• Historically successful intervention tactic
• Complimentary programs to consider (e.g., risk score accuracy improvement)
• Load-balancing considerations

Targeting

Quality Improvement

Differentiators

ADVANCEDANALYTICS

Targeting

Quality Improvement

Differentiators

ENGAGEMENT & OUTREACH

Member

Provider

Incentives

ENGAGEMENT & OUTREACH

Member

Provider

Incentives

Member Experience

ENGAGEMENT & OUTREACH

Member

Provider

Incentives

Provider Training

ENGAGEMENT & OUTREACH

Member

Provider

Incentives

ePASS® EMPOWERED POINT OF CARE INTERVENTIONS

ProviderEncounter

Retail ClinicAssessment

In-HomeAssessment

Virtual Health Visit

Benefits

Add Quality

ePASS® EMPOWERED POINT OF CARE INTERVENTIONS

ProviderEncounter

Retail ClinicAssessment

In-HomeAssessment

Virtual Health Visit

Benefits

Add Quality

Footprint

ePASS® EMPOWERED POINT OF CARE INTERVENTIONS

ProviderEncounter

Retail ClinicAssessment

In-HomeAssessment

Virtual Health Visit

Benefits

Add Quality

ePASS® EMPOWERED POINT OF CARE INTERVENTIONS

ProviderEncounter

Retail ClinicAssessment

In-HomeAssessment

Virtual Health Visit

Benefits

Add Quality

Provider Credentialing

IHA vs VHV

Compliance

CMS Guidelines

ePASS® EMPOWERED POINT OF CARE INTERVENTIONS

ProviderEncounter

Retail ClinicAssessment

In-HomeAssessment

Virtual Health Visit

Benefits

Add Quality

ePASS® EMPOWERED POINT OF CARE INTERVENTIONS

ProviderEncounter

Retail ClinicAssessment

In-HomeAssessment

Virtual Health Visit

Benefits

Add Quality

ePASS® EMPOWERED POINT OF CARE INTERVENTIONS

ProviderEncounter

Retail ClinicAssessment

In-HomeAssessment

Virtual Health Visit

Benefits

Add Quality

ePASS® EMPOWERED POINT OF CARE INTERVENTIONS

ProviderEncounter

Retail ClinicAssessment

In-HomeAssessment

Virtual Health Visit

Benefits

Add Quality

MEDICAL RECORD REVIEW

Collection & Interoperability

Abstraction & NLP

Benefits

Tools

Results

Compliance

MEDICAL RECORD REVIEW

Collection & Interoperability

Abstraction & NLP

Benefits

Benefits

Client Examples

Use Cases

MEDICAL RECORD REVIEW

Collection & Interoperability

Abstraction & NLP

Benefits

Use Case

Benefits

User Interface

35M+

229K+

Benefits

• Industry leader 20+ years MRR program experience across quality measurement and risk score accuracy domains and Medicare, Medicaid and ACA markets
• Customized, flexible and modular solution suite expertly-designed and guided by comprehensive client surveying & feedback
• Substantial overflow capacity (retrieval & abstraction) and rapid implementation in as little as two weeks to augment or replace a current MRR program with no disruption
• Scalable approach enables clients to get the support they need, when they need it – regardless of chase volume or time of year
• Deep policy, regulatory and clinical subject matter expertise with extensive oversite and internal audit practices ensure compliance & accuracy

nationwide provider EHR connectivity

medical records retrieved & reviewed

MEDICAL RECORD REVIEW

100%

20+

Collection & Interoperability

MRRV pass rate over the past 5 years across 2000 IDSS submissions

years industry experience & effective provider & site management

Abstraction & NLP

10x

96.5%+

improved automated collection

Benefits

4x

average validation rate in coding & documentation accuracy

faster natural language processing

Proven Processes Delivered On-Time

Inovalon's end-to-end submissions solutions and subject matter experts partner with health plans to deliver complete, accurate & compliant submissions, on-time.

CLAIMS SUBMISSION

MA & ACAExperience

Audit Support

Benefits

Data Integration& Aggregation

Data ValidationEngine

Risk Score AccuracyEngine

Error Correction & Prioritization

Data Visualization & Reporting

SubmissionEngine

Experience & Proven Results

Inovalon’s experts have more than a decade of proven success in risk score accuracy and RADV programs across all lines of business. Inovalon’s submissions solutions ensure compliant claims and data submissions with an average acceptance rate of 98.9% across RAPS, EDS and EDGE Server submissions to deliver a complete, accurate, and secure submissions process, mitigating audit risk.

EDS

RAPS

EDGE

CLAIMS SUBMISSION

MA & ACAExperience

• Since 2011
• 75M+ Medicare Patient Encounters submitted

• Since 2007
• 200M+ Medicare Patient Encounters submitted

• Since 2014
• 870K+ enrollment records submitted
• 7.5M+ medical & pharmacy records submitted

Audit Support

Benefits

98.5%

99.1%

99.0%

acceptance rate

acceptance rate

acceptance rate

RAD-V Process for Medicare Advantage

The RADV process involves sampling and review of medical records, payment error estimation, reporting, disputes and appeals. Estimates of financial penalty from inadequate documentation exceed $10 million even for small MA plans, so failure to manage any step of RADV can result in serious financial penalties.

CLAIMS SUBMISSION

Sampling

Medical Record Review (MRR)

Payment Error Calculation & Contract-Level Extrapolation

Preliminary Report & Dispute

Appeals

FinalReport

MA & ACAExperience

Audit Support

Benefits

1700+

229K+

Benefits

active NP network for in-home & retail clinics

providers connected nationwide

• Industry leader with over 20 years experience in Quality Improvement & Risk Score Accuracy

• Rapid implementation & proven results

CLAIMS SUBMISSION

>143%

Member choice increases completions by:

MA & ACAExperience

13-24%

risk score accuracy value achieved versus competitive tools

Audit Support

2.6-5.5x

94.4%

Benefits

Medicare Advantage members are more likely to be continuously enrolled for 2 years

member satisfaction

92+%

providersatisfaction

Delivering Differentiated Value

Analytics informed by data pertaining to more than 314M patients and 53B medical events, and 552K clinical facilities

RESULTS DELIVERED

End-to-end capabilities, including integrated risk score accuracy, quality improvement, population health

InterventionMetrics

Reporting

Inovalon’s ROI-configurable program yields an average:

• Medicare: 5:1 to 9:1 ROI; 3% to 15% risk factor improvement
• Commercial ACA: 4:1 to 8:1 ROI; 3% to 15% risk factor improvement
• Medicaid: 2.5:1 to 5:1 ROI, 3% to 15% risk factor improvement

Client Examples

Enables performance benchmark against peers for Medicare, Commercial ACA and Medicaid lines of business

Intervention Results by LOB

Inovalon's integrated risk score accuracy improvement program has a history of strong outcomes, based on our decade-plus of experience in this space. Yields and risk score impact vary by client and LOB, depending on the level of "intensity" desired by each individual client. Sample results across all clients are summarized below.

RESULTS DELIVERED

Medicare Advantage

Commercial ACA

Managed Medicaid

InterventionMetrics

Average RFI

Average RFI

Average RFI

Average FY

Average FY

Average FY

$589

$913

$464

0.183

0.102

0.071

Encounter Facilitation Results

Reporting

$1179

$1008

$1642

In-Office Encounter Support

0.233

0.231

0.199

Client Examples

Supplemental Member Encounters (IHA & RCA)

$2117

$4804

$6246

0.276

1.076

0.756

$247

$683

$601

0.022

0.019

0.031

Medical Record Review

Average ROI: 5:1 to 9:1

Average ROI: 4:1 to 8:1

Average ROI: 2.5:1 to 5:1

RESULTS DELIVERED

InterventionMetrics

Reporting

Client Examples

Providing One Single Source of Truth

Improved Operational Efficiencies & Value

RESULTS DELIVERED

Client Examples

InterventionMetrics

Advanced Analytics & Member Choice

Reporting

Advanced Analytics + Member Engagement+ POCS

Client Examples

Driving Risk Accuracy Improvement Through Connectivity