Medical and Medicaid Management

Identify the patterns that reveal savings.

Medical & Medicaid Management helps you identify critical patterns and correlations that reveal exactly where to find savings. By pinpointing areas to take strategic action, mitigate catastrophic claims and promote better health, health plan staff gain an improved understanding of cost and quality drivers and at-risk populations—fully equipping them to steer quality, timely care toward their highest cost members.

  • Identify high-risk members for care management

  • Track enterprise-level performance

  • Gain greater insight into populations with chronic conditions

  • Share performance metrics organization-wide

  • Measure utilization across various service categories

  • Aggregation

    Medical and pharmacy claims, membership, authorization and provider data provide a complete, interconnected view of organizational performance—from strategic healthcare economic issues to specific care management opportunities.

  • Interpretation

    Predictive analytics identify opportunities for intervention and prevention.

  • Transformation

    Share insight with plan staff and providers to organize, prioritize and target care, lowering both risk and cost.

Track quality concerns specific to Medicaid

Track quality concerns specific to Medicaid

Monitor policy impact on disparities and access to care

Monitor policy impact on disparities and access to care

Track key performance metrics to identify opportunities for cost savings

Track key performance metrics to identify opportunities for cost savings

Identify variations and monitor utilization by service type

Identify variations and monitor utilization by service type

Key Performance Indicators

  • Total Healthcare PMPM
  • 30-Day All-Cause Readmission Rate
  • ACE or ARB Medication Possession Ratio
  • Average Risk
  • Ambulatory-Sensitive Admission Spend
  • Dual Eligible Enrollment
  • Potentially Avoidable ER Utilization by Asthmatics
  • Well Child Visits 3-6
  • Non-Maternity Readmission Rate

What It Offers

  • Executive dashboards
  • Quick dive into claim-level data
  • 90-day implementation
  • Flexible metrics and definitions that match your organization
  • Refresh data nearly instantaneously
  • Access on the iPad

Complementary Solutions

  • Employer Reporting

    Employer Reporting provides collaborative, high-tech health plan cost analysis tools and reporting that inspire more efficient and better-utilized benefits plans. With unprecedented transparency, health plans can aggregate, analyze and share plan-use analytics with employer groups as well as analyze the plan’s total population internally.

  • Provider Engagement

    Our Provider Engagement solution brings a whole new level of health plan - provider transparency. By giving a critical view into the claims life cycle, provider networks and value-based contracts, health plans can collaborate with providers to identify the root causes of underperformance, and pinpoint what’s driving high-performing partners as well. Not only does that mean fewer appeals and errors, it means greater member satisfaction and more transparent provider relationships.

Questions? Talk to one of our experts. Contact us