Medicare and Commercial Casualty Recovery

Client: Medicare Advantage Plan
Period of Performance: May 2002 – Present

We have been working with a Medicare advantage plan covering over 250,000 lives. Our focus is on third party liabilities for the Medicare risk population. Using our subrogation software platform, our enhanced identification tool filters and scrubs medical claims based on diagnosis codes and a series of additional proprietary fields approved by the client in advance. Through our action oriented member centric communication process we then determine if the case is viable or non-viable. Our comprehensive investigation and communications processes help determine the relevant liable third party source of recovery and our skilled staff of experts tightly manages all claim and case activity to maximize the settlement ratio for each opportunity. Upon recovery, our service team transfers the funds directly to our client for processing.

Our customized process has provided an increase in subrogation recoveries of over 65% vs. their previous program results.

National Disease Management Company

Client: National Disease Management Company
Period of Performance: Present

We have been working with a leading disease management company focused on high-cost individuals suffering from chronic medical conditions compounded by psychosocial co-morbidities. Our client wanted to gauge and demonstrate the impact of their programs to sales prospects. They used exhaustive, resource-consuming analytics to accomplish this - which ultimately proved ineffective. The client also wanted to demonstrate their abilities to sales prospects without having them submit data.

We understand the complexities of efficiently running disease management programs, and effectively demonstrating to clients the positive and negative impacts of such programs.

Our proprietary opportunity projection software enabled them to-

Estimate disease prevalence
Estimate utilization rates, PMPM costs and savings potential based on available plan demographic and geographic information
Generate impact reports
Eliminate time consuming requests for prospect data
Provide their sales teams with opportunity projections
Shorten sales cycles
Provide client-specific performance measures
Improve their competitiveness with other disease management companies

Large Managed Care Organization

Client: Large Managed Care Organization
Period of Performance: Present

Our client is a regional managed care organization (MCO) covering more than 4 million members. The firm operates an integrated care management program that is mostly internal, with limited outside vendors. Our client, like most in the industry wanted to understand the risk exposure for members with chronic conditions. They were also interested in determining the potential impact of integrated care management programs, and track its progress and effectiveness.

We quickly studied what needed to be done, to help them achieve this. Our first step was to develop a data warehouse using three years of claims and eligibility data. Secondly, we constructed predictive models using risk adjusted data, and finally developed a financial and operations model that could assess chronic disease prevalence; determine potential savings from integrated care management programs; identify internal staffing resources requirements; support pricing and service level guarantees; and design outcomes analysis and reporting methodologies.

Our three-tiered approach was extremely successful and resulted in it being incorporated into the company’s pricing processes. Our financial models became a growth driver of integrated care management programs, and our precise identification of members resulted in greater financial opportunities for intervention and outcomes analysis. Our client was delighted with the results and we continue to work with them on evaluating other care management programs.