The Technology and Processes HealthJoy Uses for Facility and Provider Steerage and Population Health Management

At HealthJoy, we know better than most the impact that choosing the right medical facility or  provider can have on healthcare outcomes and cost. We don’t take our recommendations lightly and have developed sophisticated internal processes and technology to deliver superior results compared to review sites or referrals alone.

Here’s how we do it


We direct members to the highest quality, best priced, and most convenient facilities based on each specific situation. We’re able to do this because our platform integrates health plan information, medical needs, member preferences and past interactions to guide our research.

We use a number of different sources to analyze both price and quality for our members. Our ability to access relevant member data greatly impacts our decision support process. We also apply an analytical technology layer that uses artificial intelligence, data mining and predictive modeling for all our recommendations. A number of factors based on client plan design and data partners affect how we go choose the most appropriate data source. Claims data is of course more accessible for larger, self-insured clients. We also have access to and consider cash options when applicable.

All recommendations are vetted by our in-house healthcare concierge team that consists of people from both the healthcare and insurance space.

Fully-Insured Employers


With fully-insured plans through a direct carrier relationship, we depend on data partners for historical claims information. Our in-house data warehouse from self-insured clients is often applicable, and we use third-party data from both public and private providers like CMS. Public medicare data has a strong correlation to commercial data. For quality metrics, we use a combination of member feedback, CMS data, and other 3rd party sources. We use a statistical regression analysis in judging these sources and data points to deliver our recommendations.

Self-Insured Employers


The great thing about self-insured companies is that they have more robust access to their historical claims data which can be used for facility and provider steerage. HealthJoy will work with a third-party administrator (TPA) and consultant to collect historical claims pricing data. We’ve found that the detail of this data varies greatly by carrier or TPA. Our artificial intelligence-driven predictive risk modeling and data mining helps identify at risk people and gaps in care. We can use this data to be proactive in our approach and use JOY our virtual assistant to contact members. It’s this technology that separates us from “old school” nurse lines and typical phone-based advocacy services. We’ve even built a custom CRM for our in-house concierge staff that uses artificial intelligence to help find the perfect provider or facility for member needs.

Cash Pay Options for Facilities and Providers


In addition to evaluating options through an employer’s plan, we also have partners that provide cash options for procedures and diagnostics that are often more affordable than going through insurance. Over the last few years, cash options have become more relevant as they enable both employers and employees to understand the price up-front and get a better deal. The cash prices most of the time represent a bundled price, which mean that it’s all inclusive without surprises. It might include the cost of a visit, facility fee, provider fee and any post-procedure care.

HealthJoy is always looking to bring forward new and innovative strategies to deliver the best possible experience for our members. Our advanced technologies in addition to our excellent service staff delivers an experience that is redefining the healthcare experience.

Why nurse lines alone don’t cut it

We’ve spent three years developing a healthcare engagement platform that leverages artificial intelligence and virtual assistant technology for a reason. Over 80% of our inbound and outbound client interactions are handled by our virtual assistant. This frees up our staff to perform higher level tasks that “Old School” services must do manually. Things like asking members for form data, submitting prescriptions, uploading medical bills, etc. These little things add up and can take a lot of time for a nurse line to perform.

If the average registered nurse has an hourly rate of $32.66 an hour in the United States… how many outbound calls can you really expect them to make?  If the average call lasts just 15 minutes, it would cost them $8.16 per outbound call. This doesn’t even taken into account busy signals, no answers, time to dial, call-backs, etc. Would you expect them to really make outbound calls and engage your members? Yes, they might do a little claims data analysis every quarter or at the start of the program and tackle the worst offenders, but… what about the rest of the members? What about the rest of the year? We’ve designed our system to be proactive from the start, engaging all members consistently before there’s even a problem.

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