EY Nexus for Health

Products to transform health care

EY Nexus for Health features a constantly evolving suite of products that are quick to build and easy to adapt, fitting seamlessly into your existing systems and channels to address key customer needs. You can also evolve your products and services using the core EY Nexus platform, which is a versatile, cloud-ready framework with ready-to-use building blocks of technology assets and leverage the EY Partner Ecosystem.

Payer solutions:

EY Medicare Advantage Stars Terminal

For Medicare Advantage health plans, star ratings across 45 key performance indicators can make all the difference in securing a larger share of the market — and a bonus from the Centers for Medicare & Medicaid Services (CMS) to the tune of $29 to $35 per member, per month, among other benefits. Yet, each measure is weighted differently, and the cut-point thresholds for star ratings in each measure are not shared in advance. Furthermore, our team continually monitors rate changes and other program updates from CMS to validate that our models and tools provide up-to-date guidance on reporting thresholds and other key areas.

Using an end-to-end approach with intuitive dashboards, the EY Medicare Advantage Stars Terminal is a platform that demystifies the path to improvement. It’s your conduit for turning these abstract, disparate measures, based on many data sources, into improved star ratings, better care and enhanced performance, with quantifiable returns. Diagnostics help users identify the right set of contracts to focus on; predictive capabilities illustrate where gaps exist and reveal the benefits of closing them; and incentives ultimately reward behaviors that deliver results — and higher rankings. Those are some of the capabilities delivered in this one-stop shop for optimization. Learn more.

Interoperability - Electronic Prior Authorization (ePA)

The US government has recently stipulated that prior authorizations (typically required by payers for high-expense or non-routine treatments) must be electronically enabled by the end of 2024, especially for Medicare Advantage plans. Given that prior authorizations have historically been based on archaic phone or fax communications, both payers and providers need out-of-the-box solutions that can be rapidly deployed and utilized by hospital mid-office and payer staff.

The EY team provides a full suite of ePA assets to support payers:

1. CDS Hooks
2. DTR on FHIR¹
3. FHIR form templates
4. Assessment frameworks
5. Wireframes

In addition, the EY ePA solution set contains workflows for musculoskeletal, orthopedic and other high-impact treatments, which are likely use cases for ePA in Medicare Advantage plans.

¹ DTR on FHIR means Documentation Templates and Rules on Fast Healthcare Interoperability Resources.

Cost of Care Optimization

Medical cost trends reporting has primarily been request-based, limiting development of exhaustive assessment and root cause analysis. A reduction in medical costs can be achieved through an integrated and holistic approach to adjusting cost management levers such as medical policies, pre-authorizations and more with the ability to: 

• Identify member condition and site of care as well as type of service-driven medical cost trends
• Identify potential medical cost optimization opportunities by leveraging claims and a hypothesis-driven approach
• Derive research-driven chronic-behavioral conditions “crosswalks” to identify correlated conditions and manage population health much more effectively

Risk Adjustment Toolkit

By leveraging sophisticated analytics techniques, payers can optimize their risk adjustment strategies, improve financial outcomes, and ensure equitable access to quality healthcare for all members by:

• Calculating and validating risk adjustment factor for each member using models
• Capturing new and uncoded diagnosis (suspect analytics)
• Periodically confirming the presence of chronic illnesses and pre-existing health conditions in members
• Care and disease management via programs analysis and recommendations

Provider solutions

Interoperability - Electronic Prior Authorization (ePA)

The US government has recently stipulated that prior authorizations (typically required by payers for high-expense or non-routine treatments) must be electronically enabled by the end of 2024, especially for Medicare Advantage plans. Given that prior authorizations have historically been based on archaic phone or fax communications, both payers and providers need out-of-the-box solutions that can be rapidly deployed and utilized by hospital mid-office and payer staff.

The EY team provides a full suite of ePA assets to support payers:

1. CDS Hooks
2. DTR on FHIR¹
3. FHIR form templates
4. Assessment frameworks
5. Wireframes

In addition, the EY ePA solution set contains workflows for musculoskeletal, orthopedic and other high-impact treatments, which are likely use cases for ePA in Medicare Advantage plans.

¹ DTR on FHIR means Documentation Templates and Rules on Fast Healthcare Interoperability Resources.