Edifecs Launches Agentic AI Platform to Solve Value-Based Payment Challenges

HIT Consultant – Read More

What You Should Know:

– Edifecs, a Cotiviti business, has launched the next generation of its Population Payment Management platform, which is now powered by agentic artificial intelligence (AI).

– The enhanced solution is a practical and scalable application of AI designed to address persistent challenges in the shift to value-based payment (VBP).

How Agentic AI is Revolutionizing VBP

At the core of the platform are intelligent, task-oriented AI agents that understand VBP program design and payment objectives. These agents automate traditionally resource-intensive tasks, helping organizations to scale value-based programs faster and lower administrative costs. By improving settlement speed and accuracy, the agents can also reduce both administrative and medical loss ratios, which in turn enhances financial performance for healthcare payers.

Edifecs’ approach to agentic AI prioritizes responsible deployment with human oversight. The agents are not used for clinical decision-making, but instead are purpose-built to streamline workflows and provide actionable insights on contract performance and financial outcomes.

The Challenge of Scaling Value-Based Care

The shift to value-based care is gaining momentum. According to the Health Care Payment Learning and Action Network (HCP-LAN), VBP arrangements accounted for 45.2% of U.S. healthcare payments in 2023, up from 41.3% in 2022. Within these arrangements, models with two-sided financial risk rose to 28.5%. However, many organizations still struggle to scale VBP contracts without straining administrative budgets and lack effective performance monitoring. These challenges limit their ability to confidently take on additional risk.

The Power of Specialized AI Agents

The enhanced Population Payment Management platform introduces three specialized AI agents to help organizations navigate these challenges:

Virtual Jonathan (VJ): This agent acts as a data analyst, providing natural language access to contract terms and performance metrics. Users can explore data, get answers to ad-hoc questions, and generate operational analytics on demand without needing to use SQL or complex report building.
Dashboard Agent: This agent instantly converts natural language requests into customizable dashboards, enabling conversational, interactive analytics.
Deep Research Agent: This agent proactively identifies key trends, variances, and performance risks, and provides guided recommendations to improve financial, quality, and operational outcomes.

In a future update, these agents will be able to coordinate with each other to solve complex analytical challenges that would typically require entire teams and significant time to complete.

“Value-based payments are essential to building a more sustainable healthcare system, but operational complexity has slowed progress,” said Venkat Kavarthapu, EVP of operations at Edifecs. “By embedding intelligent agents directly into our Population Payment Management platform, we’re helping our customers scale programs faster, cut costs, and improve performance. This marks a shift from theoretical AI to practical solutions that understand the nuances of value-based contracts while processing healthcare data securely, at scale, and in compliance with industry standards.”