Uncovering Hidden Kidney Risk: How Health Plans Can Close the Visibility Gap in CKD Identification
Chronic Kidney Disease (CKD) is one of the most underrecognized and costly conditions in American healthcare. According to the CDC, nearly 37 million adults have CKD, yet as many as 9 in 10 adults with CKD do not know they have it. This silent epidemic leads to missed opportunities for early intervention, delayed diagnoses, and escalating healthcare costs when patients reach late-stage disease.
For health plans and risk-bearing providers, this gap is both a clinical challenge and a financial blind spot. Undiagnosed CKD can result in missed clinical interventions that could have slowed kidney disease progression, adverse patient outcomes, and underpayment. It represents a clinically driven opportunity to improve outcomes, improve accuracy of patient health condition documentation, and reduce near-term and long-term total cost of care.
Somatus CKD ID™ offers a scalable, data-driven approach that helps payors find members with probable but undiagnosed CKD, validate diagnoses with treating providers, and work with those providers to more closely monitor and manage the patient’s CKD, and integrate cases meeting clinical diagnosis criteria into appropriate care management programs. This ensures members receive the right care earlier, delivering measurable savings and improved outcomes.
THE SCOPE OF THE PROBLEM
CKD affects approximately 1 in 7 U.S. adults, yet more than 9 in 10 do not know they have it¹. The disease progresses quietly: members often do not develop symptoms until they have lost significant kidney function. If CKD is diagnosed in its later stages, the opportunity to delay disease progression is more limited and the treatment costs rise exponentially.
For payors, the consequences are profound:
Missed diagnoses lead to kidney disease being first diagnosed in later stages and inaccurate and underpaid premiums for members with CKD.
Late-stage CKD and End Stage Kidney Disease (ESKD) members cost health plans up to 1.6 times more annually than early-stage members.²
Quality ratings can be impacted, as undiagnosed members will not be enrolled in in CKD programs designed to deliver measurable clinical and quality improvements.
As an example:
100,000-MEMBER
Medicare Advantage plan may have an estimated
12,900
undiagnosed
CKD members
7,500
of whom are already
Stage 3, 4 or 5
In addition to adverse impacts on CMS quality measurements, that represents approximately $10 million in underpaid premiums and $57 million in avoidable medical expenses each year.*
WHY TRADITIONAL DETECTION METHODS FAIL
Despite widespread availability of claims and lab data, current detection models often fail to identify CKD early
enough to make a difference.
SYSTEMIC LIMITATIONS INCLUDE:
- Incomplete data feeds: Not all lab results make it into payor systems, making it more challenging for critical estimated glomerular filtration rate (eGFR) and albumin-creatinine ratio (ACR) results to be integrated and appropriately intervened upon.
- Fragmented care: Primary care physicians, specialists, and labs often operate in silos with limited data sharing and interoperability.
- Coding gaps: Even when lab results indicate CKD, diagnosis claims codes can be missing or incorrect.
- Reactive analytics: Many analytic solutions predict utilization, not the presence of undiagnosed disease.
The result is a population that slips through the cracks – patients who could have benefited from early intervention,
but instead progress to costly, irreversible kidney failure and the need for dialysis and/or kidney transplant.
THE HUMAN TOLL
When a CKD diagnosis is missed, an opportunity to intervene earlier to slow disease progression is also missed. A 65-year-old with hypertension and diabetes may see multiple providers each year, yet slowly declining kidney function may not be prioritized. By the time the decline in kidney function is more advanced, the member may have reached a later stage kidney disease and may have missed the opportunity for earlier intervention that could have significantly slowed CKD progression.
The Opportunity for Health Plans
Early identification of CKD transforms both clinical and financial outcomes.
Cost: Early guideline-directed intervention delays disease progression, with an opportunity to reduce total medical expenses by thousands per member.
Revenue: Accurate coding captures the appropriate premium for members with CKD.
For payors, addressing CKD diagnosis rates is one of the most direct paths to improving both member outcomes and accurate premium payments
SOMATUS CKD ID™: A SMARTER, VALIDATED APPROACH
- Detect the Unseen
AI-driven analytics fuse claims, lab data, pharmacy data, and social drivers of health data to detect subtle
patterns – such as medication combinations, lab trends, or diagnostic code clusters – that signal probable but undiagnosed CKD. - Validate the Finding
Somatus-employed providers or network partners contact members and their PCPs to confirm diagnosis through lab testing or chart review, where diagnoses meet clinical standards. - Drive Action
Once confirmed, members are seamlessly referred into existing care management programs or to an in-network provider as clinically appropriate. No new infrastructure is required. This ensures the insight translates to improved care, not just a data point.
In short:
Somatus CKD ID™ doesn’t just predict CKD – it confirms, codes, and connects members to the right care at the right time.
PROVEN OUTCOMES
In partnership with regional and national health plans, Somatus has demonstrated:
- Significant increases in confirmed CKD diagnosis rates within 90 days of CKD ID™ deployment.
- Appropriate capture of CKD Hierarchical Condition Categories (HCCs), translating to more accurate or appropriate premium revenue.
- Reductions in avoidable inpatient and emergency utilization for identified members.
- A measurable decline in disease progression rates among engaged populations.
Health plans typically realize positive ROI within the first year through a combination of increased premium accuracy and with reduced medical spend and compounded cost savings over time.
IMPLEMENTATION AND INTEGRATION
Launching CKD ID™ requires minimal disruption:
- Data Feeds:
Somatus integrates existing payor data (claims, labs, pharmacy). - Model Deployment:
Predictive models are calibrated to plan-specific populations. - Care Integration
Identified members flow into the plan’s current care management pathways. - Provider Diagnosis:
Providers confirm diagnosis and code appropriately.
Value is typically generated within 30–90 days, with sustained improvement in premium accuracy.
WHY IT MATTERS
Somatus CKD ID™ is a quality initiative that results in accurate premiums for health plan members with CKD. Earlier, appropriate CKD diagnosis enables earlier interventions that can slow disease progression and allow members to live healthier, fuller lives.
For payors, it represents a win-win: Better health outcomes and more accurate premium revenue. By partnering with Somatus, health plans can close one of healthcare’s most persistent visibility gaps, turning unseen risk into measurable results.
By partnering with Somatus, health plans can close one of healthcare’s most persistent visibility gaps, turning
unseen risk into measurable results.
References:
2. United States Renal Data System. 2025 USRDS Annual Data Report: Epidemiology of kidney disease in the United States. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, 2025. Table 6.3.
Contact Somatus:
To learn how Somatus CKD ID™ can identify hidden kidney risk within your membership and improve plan performance contact [email protected].