Rapidly identify cost saving opportunities to enhance claims payment integrity.
Healthcare management services face similar challenges seen throughout the industry in the journey to value-based care. Changing provider reimbursement, new risk sharing models, narrow networks and low member engagement are placing increased focus on UM systems’ ability to control administrative costs.

UM systems have traditionally occupied the role as the “cost gatekeeper” of a health plan, but with increased attention across the industry on improving quality and member engagement, UM systems are one of the most vital mechanisms health plans can leverage to equip members with information needed to manage care and drive more meaningful engagement, align provider and health plan reimbursement incentives, and curb administration costs. Yet, at their core UM systems are plagued with legacy challenges:

  • Disparate claims and payment systems that do not communicating effectively
  • No established KPIs or benchmarks to track organizational progress
  • Reliance on manual processes leads to inaccurate claims determinations and payments
  • Misaligned policies and procedures contribute to inaccurate service codes and claims adjudication
  • Ineffective technologies can’t support system integration between UM and claims
  • Repeated over payments result in poor financial management and lost revenue

When assessing our clients UM capabilities, we ask:

  • Do you feel confident in your payment integrity from service to UM to Claims to authorizations?
  • Is there a certain member demographic you need to monitor better to control costs?
  • What are your current reporting mechanisms, and do they accurately measure authorizations to adjudication ratios?
  • What percentage of approvals come in manually vs clinically?
  • Are claims and authorizations integrated in the current system?
  • What error-prone and duplicative process are of highest concern?

Lower administrative cost through accurate claims adjudication by eliminate inconsistent rules.

Our end-to-end optimization solution detects administrative cost and optimizes financial effectiveness by eliminating manual processes through correct system process determination and claims engineering.

Our E2E team focuses on synchronizing the pre-service and post-service authorization processes, rules, systems, and guidelines to drive a more accurate and unified UM to claims framework. We instill payment integrity by establishing an aligned business architecture with key performance indicators through repeatable processes and defined success measures.

Our End to End approach: 

  • Mobilizes a structured assessment approach by identifying business challenges and key resources by defining desired outcomes 
  • Discovers opportunities by gathering information in an organized way through stakeholder and SME interviews, then exam information/data for common themes
  • Evaluates themes through a deep-dive analysis and confirm finding with supporting data
  • Quantifies findings and determine impact/ exposure through establishing benchmarks
  • Establishes a plan and facilitate working sessions to address improvement opportunities and execute future initiatives

The Next Generation of UM

Our end-to-end approach delivers health plans with an all-encompassing solution to UM optimization. What we refer to as “the next generation of UM,” our solution weds policy, process, and technology from medical policies through the claims adjudication process and opens up the potential for a more enhanced role for UM systems. Moving UM systems from their historical role as a “cost gatekeeper” to a “cost optimizer” is anchored by a coordinated and aligned claims adjudication and payment process.

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