AArete helps payers identify and capture opportunities to ensure your network is meeting your objectives. Whether your goal is to be more competitive, to create an access advantage, to be more engaging with providers, to improve the quality of services and experience for your members, or all of the above, AArete brings market intelligence, data analytics, and the implementation experience to help. A few of our more common services for health plans include:

Provider Contracting: Whether you are creating a new network or looking to maintain or enhance an existing one, AArete can help to ensure it is market competitive.

Network Optimization and Sculpting: We help identify high performers, based on a customized definition of performance so that we can help you enable cost effective, high quality services for your members. This can be a broad network effort or one more focused on certain elements such as PCP’s (primary care), specialists, or various ancillary services.

Value-Based Contracting: Our market intelligence and analytics can help you adopt effective strategies for getting the most out of value-based provider payment models, from shared savings to provider assumption of significant risk and the various financial, administrative, and quality considerations.

Capitated Arrangement Reviews: If you capitate with a provider—paying a fixed amount for the health of a population—AArete helps ensure that your contracts are adhered to, and that those contracts generate the savings or benefits you need.

Network Steerage: AArete helps identify and implement site of care opportunities for members to receive services at less costly places of service.

Network Development: We build out provider high performance networks by satisfying, state access requirements, cost, quality, and affiliations considerations.

Network Adequacy: Our analytics can assess member access to care and identify geographic areas and provider types where network is at risk or not compliant to state requirements.
 
In all cases, AArete not only identifies gaps and opportunities, but also works with you to make sure that you realize the identified benefits.

AArete helps payers apply appropriate policies and techniques to influence
how members utilize services. For example, case management techniques
reduce the cost of coordinating hospital care for chronic conditions such as diabetes—and AArete can use advanced data analytics to identify members
who need case management. We can also help you ensure that case managers (and their managers) get the right data, methodologies and interpretation tools they need to do their jobs well. We bring similar approaches to disease management, where our predictive models are especially valuable at the
crucial early identification of at-risk members in all stages of a disease.

AArete helps payers in policy review and market alignment, making sure that
you are using commonly adopted market best practices. As with all of our services, we marry our market intelligence with data analytics capabilities and
a focus on implementation, to make sure that we not only identify improvement opportunities but also help you accomplish them—guaranteed.

Utilization Management: AArete provides market intelligence and data analytics
in order to create customized strategies to reduce utilization management.
 
Case Management: Using data analytics, AArete identifies individuals that
should be in case management, which ones should not, and how to prioritize
them in the most effective way. AArete also evaluates case management from a functional perspective to optimize caseloads and increase output.
 
Disease Management: AArete helps health plans develop programs for their most complex and sickest members by utilizing subject matter expertise and market intelligence.

Payment Policies: Our research and market intelligence help our clients
identify new or improved policies to implement that limit or eliminate payment
for unnecessary services while our data analytics helps quantify and prioritize policies to enact.

With a deep understanding of how health plans operate, AArete helps payers improve operations across all functions. Among the many operations projects that AArete has implemented, some common themes include:

Process Discipline: We help you define a new process or assess an existing one, identifying opportunities for improvement. From back office functions to processes that directly touch or impact your members, AArete brings that knowledge and experience to help ensure your operating with efficiency and the proper controls.

Software or System Implementation: From core claims systems to various enabling tools (e.g. claims editors, contract management systems, medical management, FWA, pharmacy tools, etc.), AArete’s helps our clients ensure optimal use and performance.

Provider Data Management: We help you review, improve and automate data processes. We help develop appropriate reporting and dashboards. And in situations where data management issues have led to a mess including incorrect payments, we help firefight: identify gaps, resolve issues and fix fundamental processes so that the problems won’t recur.

Functional Area Support: We help health plans support operational areas by providing either interim leadership or additional horsepower from our teams in order to ensure that organizational goals are met.

Annual Operating Plans: AArete helps with the process of seeking medical loss ratio (MLR) improvements through annual operating plans. We can help you ideate, vet, prioritize, implement and track your plans, either with specific expertise or in using our project management skills to drive the entire process.

AArete leverages data to reduce costs and provide better care to their members. We identify cohorts based on risk, cost to service, disease/diagnosis, geographical region, etc., that often increase costs. AArete proactively ideates and asses options for interventions to mitigate these developments and further supports implementing that intervention, all the way through reporting and tracking.
 
AArete gathers medical, pharmacy, and behavioral health data together and integrates outside data (such as population-centered income or crime data) to develop a comprehensive picture of your population. With the ability to drill down into the data to generate actionable insights, we enable our payer clients to improve health outcomes and reduce expensive health crises without straining resources.

The configuration of a payer’s claims adjudication system affects payment integrity. Many vendors provide on-going payment integrity services; However, AArete’s Payment Intelligence™ ensures erroneous payments are identified, understood, recouped and rectified to prevent them in the future. Implementing changes in configuration to address payment accuracy ultimately leads to sustained improvements in client profitability. Although some clients engage AArete to perform steady-state reviews, clients also engage AArete prior to go-live (i.e., pre-implementation configuration) or during migrations (i.e., post-merger integration).

Payment Intelligence™ benefits include: retrospective recoveries, remediation of configuration and process gaps, increased efficiencies, improved regulatory compliance, alignment with industry standards and internal policies, and enhanced provider relations. Additionally, Payment Intelligence™ helps manage reductions in administrative adjustments, optimize medical loss ratio (MLR), reduce the financial volatility from resolution of underpayments and create transparency—both internally (your reimbursement decisions) and externally (market acceptance gleaned from AArete’s intellectual property.
 
AArete collaborates with clients to customize a solution that addresses their specific needs. Payment Intelligence™ dives deep to understand root causes and implements solutions with a focus on these six key areas:

Payment Policies: Do your policies and unit limitations allow claims to be paid in accordance with regulatory guidelines and industry standards? Including those for fraud, waste, abuse and error (FWA)?
Provider Data: Is your facility, practitioner and supplier data accurate and consistent within a given TIN/Network and across your different systems/directories?
Provider Contracts: Are your reimbursements consistent with the terms and carve-outs of your provider contracts?
Member Eligibility: Do you have gaps in member data and revenue reconciliation related to enrollment, eligibility, government rosters, or cost-sharing accumulators?
Covered Benefits: Is your plan configured to pay only for covered services and in the right quantities?
Prior Authorizations: Do you ensure that services are authorized and in accordance with medical management policies before payment?

AArete’s Payment Intelligence™ uses client-tailored advanced data analytics, our Knowledge Management Center™ and our proprietary methodology to deliver effective solutions that optimize payment accuracy and maximize profitability.

AArete offers a suite of pharmacy solutions, which are clinically derived, driven by data and proven in the field, to help you identify problem areas and implement sustainable results.
 
Contract Management:
Improve pharmacy contracts to reduce costs and ensure partner accountability.
·      PBM Contract and Configuration
·      PBM Audit (Pricing, Rebates, Performance Guarantees)
·      Benchmarking and Competitive Pricing
·      Manufacturer Rebates
·      340B Opportunities
·      Network Optimization

Benefit Management:
Maximize savings through an integrated and holistic drug management model.
·      Benefit Design
·      Formulary Optimization
·      PA Review
·      Generic/Biosimilar Optimization
·      Preferred Product Strategy
·      Marketplace Comparison
·      Federal/State Compliance
·      Medical Claim Edits
 
Member Management:
Reduce costs and improve quality through coordination and management of members.
·      Channel Management
·      Polypharmacy Management
·      Negative or Redundant Drug Interaction Mitigation
·      Maximum Daily Dosage/MUE Controls
·      Opioid Controls and FWA Detection
·      Medication Therapy Management

Specialty Management:
Focus on holistic management of major cost-driving drug categories while maintaining quality.
·      Site of Care Optimization
·      Biosimilar Preference
·      Prior Authorization/Step Therapy
·      Rebate Strategy
·      Dosage Optimization
·      Disease State Management

Infrastructure:
Optimize infrastructure to achieve correct balance between insource and outsource.
·      Clinical Policies
·      P&T Committee
·      Vendor Oversight
·      PBM Long-Term Relationship Management
·      Adherence Program Management
·      Clinical Quality Improvement
·      Advanced Cost Benefit and ROI Analyses

Our market intelligence gives us familiarity with best practices in all these areas. Our strength in data analytics and focus on implementation mean that we work with you to achieve a return on your investment in our services, guaranteed.

AArete assists government-sponsored payers in taking a methodical approach to improving quality both by improving members’ lives, and by maximizing financial returns. The answer to improving Healthcare Effectiveness Data and Information Set (HEDIS) scores is found within the data. Most state Medicaid and Medicare contracts include quality measurement payouts. AArete leverages data analytics expertise to assess incentives and benchmark your current performance. These results can shed light on the organization’s most impactful initiatives. After working with AArete, one of our clients went from fourth in the state to ranking first in the state.

AArete helps our clients increase quality scores, decrease penalties, and increase bonuses, through a multi-step improvement methodology. Using data analytics, we highlight the quality measures that are the most impactful to our client’s bottom line. AArete examines any documentation issues caused by sub-optimal processes (such as reducing “chart chase”), incentives and outreach efforts to determine alignment with key measures and return on investment. AArete also analyzes provider performance in relation to the key metrics to identify providers affecting quality performance. AArete also assists clients with highlighting gaps and recommends initiatives to improve processes and programs such as Quality Assurance and Performance Improvement (QUAPI) strategies, Performance Improvement Projects (PIPs), as well as compliance with contracts, and creating or improving quality reporting.  

AArete supports payers in reducing costs and transforming operations through our results oriented and implementation focused digital and data analytics services:

·      With specialized skillsets across leading data analytics applications and platforms, supplemented by the depth of AArete domain and industry we can augment and/or build the capacity or capability of your internal analytics team through a tailored “Analytics-as-a-Service” offering.

·      We specialize in last mile analytics, drilling down from the macro-level reporting and operational dashboards to specific actionable insights that can help your team take on-the-ground action to deliver effective and timely results.

·      We build customized analytical models powered by predictive analytics and machine learning that actually address your bespoke business challenges and opportunities. We then integrate these models into your business processes so your teams can use them for day-to-day decision making and actions, driving tangible outcomes. For example, we helped one payer predict high-risk pregnancies, to reduce the time that a baby spends in an incubator; we helped another predict which opioid users were likely to become abusers.

·      We help payers find and implement opportunities in robotic process automation, in areas such as provider data management, claims, prior authorization, etc., and with our technology partners, develop solutions that are targeted, scalable and deliver ROI.

·      We help payers operationalize digital transformation efforts, especially by translating broad initiatives into specific, implemented processes to derive maximum value. For example, if you are considering a blockchain-based solution for claims adjudication, prior authorization, or provider management, we have experience going beyond use cases to actually implement and deliver ROI.

AArete uses data-driven assessments to help government-sponsored and commercial payers optimize their revenue streams. Our strategic solutions effectively capture and reconcile risk-based revenue payments, including areas in revenue adequacy and premium integrity.

AArete partners with healthcare payers on product growth strategies to increase membership and expand market share. Payers leverage AArete’s data analytical strengths to understand regional trends, assess member behavior, evaluate competitive landscapes and examine drivers for member attrition and retention. Optimizing provider networks, enhancing formulary benefits and improving member transition from one product to another are all examples that have strategically assisted payers enhance their products.

AArete advises commercial and government sponsored health plans on a variety of business issues. We have a wide range of healthcare advisory expertise to support strategy development, growth, cost reduction, operational improvement, compliance and many other initiatives. A sampling of our support includes the following:
·      Quality and Stars Implementation
·      Encounters
·      Healthcare Compliance
·      Market/Product Strategy
·      Health Plan Start-Ups
·      Insource/Outsource
·      Premium Reconciliations
·      Mergers and Acquisitions
    Pre-Deal Assessment
    Post-Merger Integration 
·      Cost of Care Program Reviews, Framework Design and Implementation