Total Cost of Care: Strategies for Health Plan Cost Containment
Reduce trend and improve affordability while protecting quality and experience.
Every health plan’s cost challenges are different, but the pressure to improve affordability and performance is universal. Rising medical costs, shifting utilization, and increasing regulatory demands require more than isolated initiatives. Improving total cost of care takes a coordinated, data-driven approach that identifies true cost drivers, implements targeted solutions, and delivers sustainable savings without compromising quality or member experience.
Total Cost of Care Solutions
Integrated solutions designed to identify cost drivers, implement targeted interventions, and deliver measurable savings across your health plan.
Claims Payment Accuracy & Integrity
POWERED BY PAYMENT INTELLIGENCE®
Reduce unnecessary spend through accurate payments, strong controls, and proactive FWA mitigation.
Intelligent claim edits to prevent waste, error, and inappropriate payments
Contract configuration and automated contract intelligence (Doczy.ai™)
CPT/HCPCS-level pricing validation and provider outlier detection to control fee-for-service cost variation
Provider directory accuracy and CMS reporting alignment to support compliance and reduce access-related payment risk
Provider data accuracy and ongoing payment rule validation to identify root causes and prevent recurring errors
Member eligibility and benefits validation to support accurate payment decisions
Policy configuration and payment rule alignment to reduce leakage and improve consistency
Prior authorization compliance to improve payment accuracy and reduce unnecessary spend
Pharmacy & Specialty Cost Management
Control pharmacy and specialty medical spend through targeted programs, vendor optimization, and continuous performance management.
- Pharmacy Benefit Mangager (PBM) payment integrity and continuous claims monitoring
- PBM strategy, vendor economics, and pharmacy cost management
- Drug spend analytics to identify cost drivers and actionable savings opportunities
- Targeted savings initiatives across pharmacy and medical drug spend
- Unit-cost benchmarking and contract optimization for PBM and medical benefits
- Behavioral health and complex member cost management
- Adaptive drug strategy aligned to market trends, pipeline, and regulatory change
Utilization & Medical Management
Control medical spend through smarter utilization management and targeted care interventions.
Medical policy alignment to industry benchmarks and best practices
Utilization pattern analytics and market intelligence insights
Operational efficiency and care management performance improvement
Capitated payment model design and performance optimization
Analytics, Benchmarking & Opportunity Sizing
Pinpoint cost drivers and savings potential using market benchmarks and performance analytics.
- Market benchmarking across 120+ health plans to identify cost performance gaps.
- Total cost of care analysis by population condition, and service category
- Utilization and trend driver variance insights
- Savings opportunity sizing with PMPM and annualized impact modeling
- Prioritized opportunity roadmap tied to financial outcomes
Provider Network Performance
Optimize provider network design and contracting to improve access, steer utilization, and control total cost of care.
Network adequacy and access optimization aligned to regulatory and market requirements
Provider network sculpting to guide members toward high-value providers
Unit-cost benchmarking and contracting performance improvement
Leakage reduction and in-network utilization steerage
Network strategy for new products, geographies, and growth initiatives
Cost Reduction Program Design & Performance Tracking
Design and execute targeted cost reduction programs with performance tracking to deliver measurable savings.
- Targeted cost reduction initiative design across priority medical spend drivers
- Population health and cohort-based intervention strategy
- Disease management and care model program development
- Care management effectiveness improvement and operational optimization
- Steerage to lower-cost, high-quality sites of care and providers
- Execution governance and benefits realization tracking (PMPM, ROI)
The AArete Advantage
Proprietary solutions that turn cost control, compliance, and accuracy into measurable results.
Timely visibility into evolving healthcare policy and regulation
Near real-time review of 100% of claims for benefit administration and payment accuracy.
Rapidly pinpoint provider outliers and uncover cost-savings in behavioral health claims.
An AI contract interpretation solution to achieve unprecedented operational efficiencies at scale.
Contract-aware configuration intelligence that fixes claims errors at the source.
Total Cost of Care Leadership
Latest Cost of Care Insights
Let’s Talk
Whether you’’re looking for a consulting partner who can adapt to your health plan’s specific needs and drive results, or just curious about our services and solutions, let’s talk.
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