HealthCare Analytics

Self-Insured Employers

• Claims audits, to meet the following objectives:
  • Claims paid and charged to the Group were on behalf of active, covered members, for covered services
  • Payments to providers were made consistent with the requirements of underlying contracts
  • The appropriate liable parties were determined based upon the Group’s subscriber agreement (was the service covered, were deductibles and coinsurance amounts properly determined and billed), site of occurrence or nature of the claim (subrogation, worker’s compensation, etc.)
• Due diligence assessments for operational viability, administrative capacity, contracting capabilities, value added services of potential merger partners
• Statistical and financial analysis of cost and utilization data for rate evaluations, trend development and premium reconciliation
• Product development and pricing for self-insured plan development
• Assessment of RFPs for self-insured plan administration

Public Entities

• Capitation rate development
• Actuarial analysis and product development
• Financial analysis
• Premium assistance program development and Monitoring
• Development, monitoring, analysis and reporting of performance measures
• Accountable Entity / Accountable Care Organization program development support, monitoring and performance reconcilation
• Cost and utilization trend development
• Analysis of cost and utilization data for key drivers

Provider Networks, ACOs & AEs

• Evaluation and cost-benefit analysis of reimbursement arrangements
• Strategic planning and operational assessment of network capabilities, capacity, and financial exposure of existing and under-review contracts / arrangements
• Auditing of contract specification performance and reimbursement rates
• Assessment of financial arrangements, risk sharing provisions
• Development break-even evaluations and pro-forma analyses of financial, risk and reimbursement arrangements
• Development of actuarially sound strategies for negotiating financial arrangements
• Monitoring and reporting of network performance, provider profiling and care management reporting

Managed Care Organizations

• Review and analysis of reimbursement arrangements and contratual terms for revenue maximization through:
  • Identification and reconciliation of attributable risk populations
  • Definition of services under contract
• Analysis of cost and utilization data for key drivers
• Establishment of baseline statistics through market analysis
• Development of actuarially sound risk management strategies
• Rate development and rate setting
• Cost and utilization trend development
• IBNR development and analysis
• Competitive analysis 
• Product development and pricing
• Financial analysis