Optimize Medical Costs & Improve Health Outcomes

Payment rates are falling and Congress is applying pressure on future rates. Still, health plans are expected to deliver the medical and pharmacy services required for a growing aging population. With less funding coming in the door and the same output expected, you will have to take action in order to retain your current success. This begins with identifying cost drivers and analyzing each to best understand how to minimize costs.

Medical & Pharmacy Trend Management

Do you receive up-to-date information on how your plans are performing against assumptions?  Do you know if the future trend is looking better or worse?

Inaccurate estimates can cost your organization millions. We can analyze your historical medical expense utilization, benchmark your claims experience against realistic and achievable targets, identify opportunities for mitigation and project future costs.

We analyzed a Medicare Advantage (MA) plan’s historical medical costs and found that an injectable drug was costing them $40 million and driving their trend up by 5%. Mitigation planning and benchmarking led to an alternative treatment option that was promoted through clinical programs and ultimately reduced costs.

Pricing & Bid Development

Are your premiums set competitively to win the business, yet cover the population risk and medical costs?  Will your organization be ready if competitive bidding becomes a component of Medicare Part C?

Finding the balance between competitive and profitable pricing isn’t easy. We can work with you to define pricing strategies; analyze the impact of product, benefit design and pricing changes; segment and identify target markets; complete revenue and cost projections; and provide bid development and rate filing support.

Payment Accuracy

How accurate is your risk-adjusted coding? Is it well-documented in the event of an audit by CMS?

CMS audits are costly when instances of non-compliance are found. We can help you avoid these monetary fines. Our consultants perform prospective payment audits, HCC code improvement reviews and other revenue-management initiatives to ensure risk-adjusted pricing accuracy and optimized reimbursement. We also assist in financial reporting, including automated Part C and D reporting solutions and Prescription Drug Plan reconciliation.

Network Development & Optimization

Do you have the optimum network to meet your member needs from an access, quality and cost perspective?  Do you have a defined set metrics to measure its adequacy?

Providing better care starts with contracting with the right providers and rewarding them for quality and effectiveness. We can help you develop your network.  Our consultants can also help integrate provider engagement initiatives with your contracting and payments, as well as perform competitor reimbursement analyses, contract analysis and modeling, and recommend contracting and pricing strategies.

Care Management

Do your care management programs deliver high quality care outcomes for your members while controlling costs?

Reduced reimbursement from Medicare will increase the pressure on care management programs to improve population health and control costs.  We help by providing everything from pay-for-performance and medical home strategies to disease, SNP and case management program design and optimization. We also evaluate your member population to define which target populations to manage and what to manage within those populations.