Healthcare: cost containment
Challenge:
The organization served as a safety net health plan, primarily serving beneficiaries in a densely populated urban geography. The newly appointed leadership sought to ensure long-term financial viability of the health plan while maintaining competitive market positioning. In particular, they needed:
- Full spectrum analysis of claim and utilization data
- Assessment of system configuration versus contract terms
- Identification of key service areas positioned to yield savings opportunities
- Evaluation of health plan reimbursement rates against the market and amendment of existing contracts as appropriate
- Savings from key vendor contracts
Solution:
Mazars assembled a project team with experience in claim data analytics, RFP execution, operational management, project management, and provider, hospital and ancillary contracting. The team worked with:
- The Managed Care Organization’s executive leadership across multiple business units establishing buy-in across the organization
- The IT and Claims Departments to extract historical claims data for analysis
- The Claim System Configurations teams to correct contract load errors
- The Ancillary and Vendor Management Departments to draft and circulate requests for proposals, score responses, transition legacy relationships and execute new agreements
- Corporate Counsel to approve provider notifications and contract revisions
- The Provider Contracting and Provider Relations Departments to amend existing provider agreements
Results:
- Transformed contracting and operating standards
- Realization of a recurring, annual medical expense savings in excess of the target by nearly 20%
- Improvement in claims payment accuracy
- Uniform, market rate fee schedules for all community-based provider types on a go-forward basis
- Implementation of contracting incentives, driving increased encounter data submission rates to enhance quality measure reporting and enrollment into appropriate care management programs
- Transformed contracting and operating standards
- Realization of a recurring, annual medical expense savings in excess of the target by nearly 20%
- Improvement in claims payment accuracy
- Uniform, market rate fee schedules for all community-based provider types on a go-forward basis
- Implementation of contracting incentives, driving increased encounter data submission rates to enhance quality measure reporting and enrollment into appropriate care management programs