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