Overcoming Challenges to Embrace Opportunity
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
Featured Solutions for Payers
Payment Accuracy Solutions
For payers that want to improve claims adjudication and streamline payment operations.
Payment Management Solutions
For payers and providers that want to streamline and optimize payment management.
Risk Adjustment & Quality Performance Management Solutions
For payers that want to identify quality gaps and improve performance ratings.
Clinical Decision Support (InterQual) Solutions
For payers, providers, and agencies to make clinically appropriate utilization decisions.
Health Plan Consumer Engagement Solutions
For payers that want to engage members with cost transparency to improve satisfaction.
Provider Contract Optimization Solutions
For payers who want to identify cost savings opportunities and automate contracting.
Value-Based Care Enablement Solutions
For payers and providers that want to improve efficiency and patient care outcomes.
Medical Network Solutions
Vast connectivity for providers and payers to optimize the claims management process.
Healthcare Consulting Services
For payers and providers that need help overcoming the challenges of an evolving industry.
Dental Network Solutions
For dental payers, providers, and partners to automate and simplify claim payment.
Pharmacy Benefits Services & TPA Solutions
For self-funded employers and TPAs that want to improve financial outcomes.