Health Plans

With the rising cost of healthcare and the evolving shift to value-based care, payers are looking for ways to optimize healthcare reimbursement. The need for new and strengthened capabilities to engage members, optimize risk adjustment and quality, enhance provider and network efficiency, prevent fraud waste and abuse and contain costs is more critical than ever. To succeed plans need to bring together fragmented data and collaborate with providers to facilitate a member-centered delivery model.

SCIO analytics solutions and services support comprehensive, holistic reimbursement initiatives that help payers control costs, reduce overall health claim expenditures and optimize revenue opportunities while improving care quality.

Through a blend of clinical review and claims audits, payment and risk adjustment analytics, and technology, we help clients detect, prevent and recover improper payments while increasing revenue related to the management of member populations.

PBMs

In today’s healthcare environment, PBMs face challenges related to the dynamic and evolving management of drug benefits for members as well as the need to reduce overall drug spend expenditures. PBMs are looking for new and strengthened capabilities to contain costs, manage pharmacy performance, integrate clinical data, automate disparate processes, enhance member medication compliance and improve fraud and abuse detection while reducing pharmacy abrasion.

SCIO’s robust predictive analytics solutions, workflow technology and prescription claim auditing capabilities help PBMs drive efficiencies in pharmacy benefits management, including a focus on high drug spend areas, and decrease prescription drug costs while enhancing care delivery.

On-demand Webinars



Provider Led Health Plans 202 - A Roadmap to Ensuring Financial and Clinical Sustainability

Held on: September 21, 2017

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Risk Adjustment Round-Up: Reviewing the CMS Call Letter and Other Trends

Held on: May 24, 2017

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Interested in learning more about our offerings for Payers?

KEY MARKET CHALLENGES:

  • Rising cost of healthcare and drug spend, with nearly $100 billion lost in overpayment of healthcare claims
  • Shortage of resources to handle claims, audits and prompt payment policies
  • Overpayments due to multiple submissions of drug claims under medical and pharmacy claims
  • Maintaining accurate risk scores to ensure reimbursement is commensurate with expected costs
  • Meeting HEDIS/Stars/P4P quality metrics
  • Understanding physician referral patterns and network leakage

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