Healthcare Payer Solutions

Empower your members across the consumer journey

Our solutions power payer consumer engagement initiatives:

• Enroll:  We help payers determine eligibility and enroll members for Medicare, Medicaid, and Dual Eligible programs

• Search for Care:  We offer transparency and provider directory solutions—along with proactive outreach to engage members

• Manage Care:  We help close gaps in care and support care management programs

• Pay for Care:  We simplify the experience, enabling members to make payments in a timely manner

Our consumer engagement platform helps more than 20 million consumers

Close gaps in care and improve quality scores

Our quality solutions and care management services help payers comprehensively improve quality programs:

• Stratify population health risk

• Identify gaps in care

• Outreach to and engage members

• Engage providers and coordinate care

• Improve reporting and value demonstration for quality performance metrics (e.g., HEDIS and STARs)

More than $60 million annual payer savings via large physician group closing quality gaps with our quality performance solution EMR Risk Advisor

Lower total cost of healthcare

Our solutions equip payers to manage utilization, unit cost, and fraud, waste, and abuse:

• Optimize provider networks and contracts
• Improve payment accuracy and integrity
• Offer decision support to improve utilization management
• Engage members to support care management programs
• Conduct population health analysis and risk stratification
• Drive payment accuracy and code editing technology and services

80% of outlier providers exhibit better billing behavior through our payment accuracy solution Coding Advisor

Drive plan revenue through better risk scoring

Our risk adjustment solutions help payers determine and validate condition data to improve risk scoring and health plan financial performance:

• Aggregate and analyze data (claims, care management, pharmacy) via advanced technology to determine gaps
• Perform clinical chart review, coding, and encounter and claims submissions
• Conduct risk adjustment data validation (RADV) audits
• Ensure compliance with risk adjustment methodologies

Approximately 3% increase in chart retrieval—averaging ~$1.5M revenue increase for plan

Develop and execute value-based programs

Our solutions can help payers create, optimize, and execute your value-based care and payment strategies:

• Analyze provider networks to create value-based payment models, e.g., bundled / episode payments
• Conduct population health and risk analysis
• Build provider networks and engage physicians to improve quality and cost performance and realize shared savings
• Deliver advanced care management and care coordination to engage members

In a joint venture with BCBS-AZ for shared savings contracts, we achieved about 2 times the provider recruitment goal in first year

Drive efficiency in plan operations and payment processing

Our solutions offer comprehensive payment processing and outsourcing services for key parts of payer operations

• Improve adoption of electronic payments to providers
• Connect to the largest EDI network in the US health system
• Reduce claims processing costs through our payment accuracy and code editing technology and services
• Plan and implement strategic and operational initiatives with the support and advice of our consulting teams
• Gain scale and efficiency for core payer operations through our pharmacy benefits and TPA services and the industry’s largest print services operation

We are driving a more than 40% increase in adoption of electronic (ACH) payments, year-over-year