We provide sophisticated tools to reduce the disparity in payer-provider interactions. Our offerings include: ● 𝐍𝐨 𝐒𝐮𝐫𝐩𝐫𝐢𝐬𝐞𝐬 𝐀𝐜𝐭 𝐓𝐮𝐫𝐧-𝐤𝐞𝐲 𝐒𝐨𝐥𝐮𝐭𝐢𝐨𝐧: The NSA requires affected providers to dispute any out-of-network insurance payments through a byzantine process. We provide a turn-key solution that transparently retrieves the money you are owed while minimizing manual input from your team ● 𝐑𝐢𝐬𝐤 𝐒𝐡𝐚𝐫𝐢𝐧𝐠 𝐂𝐨𝐧𝐭𝐫𝐚𝐜𝐭 𝐌𝐚𝐧𝐚𝐠𝐞𝐦𝐞𝐧𝐭: A move away from fee-for-service can benefit health systems, but also requires attention to detail: a single non-adhering physician, or overbooked imaging center, can cause havoc. Additionally, payers can often destroy gainshare through bad-faith interpretations of a contract. We track your performance in real-time, provide outputs to all stakeholders including physicians, and link that performance to overall gainshare to avoid nasty surprises. ● 𝐂𝐨𝐧𝐭𝐫𝐚𝐜𝐭 𝐍𝐞𝐠𝐨𝐭𝐢𝐚𝐭𝐢𝐨𝐧: The largest insurers have developed sophisticated national infrastructure to drive down costs as much as possible - for example, United pays out $250B annually which is roughly 1,000 times the total income of the average hospital. We provide legal and technical sophistication to benchmark your rates against multiple sources including price transparency, quantify how obtuse contract lines will actually affect your revenues, and redline any qualitative contract language that could be used against you. ● 𝐏𝐫𝐨𝐚𝐜𝐭𝐢𝐯𝐞 𝐂𝐨𝐧𝐭𝐫𝐚𝐜𝐭 𝐌𝐨𝐧𝐢𝐭𝐨𝐫𝐢𝐧𝐠: Insurers who can’t win discounts through aggressive negotiation often resort to increasingly sophisticated revenue cycle tricks. We monitor your billing and remittances to immediately catch these changes, allowing immediate pushback before months of losses have accrued. And if it comes down to it – we have a close working relationship with a top tier provider-focused law firm that frequently wins cases against the biggest insurers in the country.

Built out the applications and reports necessary to inform the contract negotiating process across a $14B organization. Designed a source-agnostic suite of tools which allows:- Flexible modeling, proration audit, and reporting on fee for service contracts- Net revenue impact of charge master changes- Month to month tracking of drivers of hospital revenue across volume, case mix, negotiated contract increases, charge master changes, and revenue cycle- Integration of third-party datasets with claims to create additional reports- Informed the development of CHI’s value based funds flow guidelines and philosophy; designed the attribution of funds to our physicians participating in Medicare’s Bundled Payments for Care Improvement (BPCI) initiative

Designed payment transformation initiatives for many multi-state health systems:- Facilitated creation of an ACO as a joint venture between a health system and an IPA, and its application to Medicare to take the care of roughly 25,000 Medicare beneficiaries during a 3 year ‘Medicare Shared Savings Program’ pilot- Designed cardiology co-management initiative with short-term goal of $1-2 million annual inpatient cost savings- Built out bids for several health systems to take on $2-3B of Medicare risk through the CMS Bundled Payments Initiative: work involved selection of payment structure; design of gain-sharing agreements with relevant providers; and identification of cost savings opportunities during inpatient and post-acute care- Repriced $5B in inpatient claims according to MS-DRG and APR-DRG methodologies to inform a revenue-neutral transition from per diems for a payor’s in-network facilities; modeled the short-term impact and longer-term implications of the switch- Formulated strategies and developed materials for managed care contract negotiations with total expected rate increases on the order of $30-50M

Designed a dataset of Medicare Advantage plan benefit packages and corresponding geographical enrollment:Combined publicly available data with proprietary information and Medicare knowledge to create a readily queriable SQL database designed to inform payer top-line growth and benefit designDeveloped marketing materials, channels and partnerships through which to sell projects.

Consulted on strategic and transformational projects for clients including health insurers, hospitals, and health information technology vendors. Supported two transformational engagements for $1B-revenue health insurers. Designed and built a central data warehouse by integrating disparate clinical data sources. Developed claims analysis capability for Oliver Wyman, driving future high-value engagements. Identified provider groups, locations, and employers for quality improvement programs. Ranked providers through quantitative quality metrics synthesized from medical literature. Quantified metrics with which to rank surgeons and facilities on quality and cost through claims data. Supplied data and advice to support health insurer through hospital negotiations and creation of care delivery pilot. Spearheaded development of a tracking tool to measure success of care delivery initiatives. Trained client's IM department and other Oliver Wyman analysts to conduct similar analysis.Focused a leading EMR vendor's revenue growth strategy by sizing and segmenting the provider IT market and projecting future growth. Targeted benefit design and expansion opportunities for multiple payors through extensive market research on Medicare advantage, prescription drug plans, and supplementary products .