Healthcare: cost containment

Medical expense reduction for a managed care organization

March 23, 2018

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