AArete works with health plans to improve their profitability by leveraging our experience and market intelligence to implement solutions that are customized for our clients’ unique needs. We’ve supported thousands of initiatives across a variety of health plan functions, generally classifying them by the impact they have on one of the following:
· Unit Costs
· Payment Integrity
· Member Satisfaction
· Quality and Compliance
· Operational Improvement
Our value proposition for our clients includes:
Our Footprint of Experience
We’re fortunate to have worked with over 90 health plans across the country, including 8 of the top 10 by membership size. This experience includes working with large, national payers, local and regional plans, provider-sponsored plans, as well as select blues organizations. Encompassed in our footprint is significant experience supporting efforts across 40+ states in all lines of business (e.g. government sponsored Medicaid and Medicare, as well as Commercial products).
AArete goes beyond the identification of opportunities to implement results. Many of our clients value the leverage AArete provides to complement their internal resources with the extra horsepower to realize financial improvement.
AArete leverages our centralized Center of Data Excellence (CODE), a team of data scientists and managers of our intellectual property, to put actionable analytics into the hands of our client stakeholders. This approach enables a more focused and nimble resource that can complement traditional internal medical economics teams (while enriching analysis with market intelligence).
Every engagement is rooted in the fact that we will guarantee a minimum ROI on our clients’ investment with AArete.
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.
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
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
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
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
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.
Digital & Data Services
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.
Revenue Optimization & Growth
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
· Healthcare Compliance
· Market/Product Strategy
· Health Plan Start-Ups
· Premium Reconciliations
· Mergers and Acquisitions
· Cost of Care Program Reviews, Framework Design and Implementation
Our Payer Experts
Maulik is based out of AArete’s London office and leads AArete’s Digital and Data Services as well as International Business. Overall, Maulik comes with over 15 years of experience in Operational and Management Consulting across multiple industries working with Ernst & Young, Protiviti Consulting and Huron Consulting. He has experience leading large consulting engagements for clients delivering measurable bottom line improvement, digitally enabled process efficiencies and organizational change, through fact-based data intensive analysis combined with domain expertise. Maulik holds a Master of Business Administration degree from S.P. Jain Institute of Management and Research (SPJIMR), a Bachelor in Accounting and Finance from Mumbai University, and is a Certified Information Systems Auditor and a Six Sigma Green Belt. He is a published author and quoted industry expert in Managed Healthcare Executive, Chain Drug Review, ThinkAdvisor, American Pharmacists Association and Chain Store Age.
Kevin specializes in data analytics and mining, business process improvement, strategic sourcing solutions and leading strategic profitability improvement initiatives. His broad range of healthcare experience, including both the Provider and Payer side, makes him an integral member of AArete’s analytics team. Kevin has worked with large managed care organizations (MCOs) and hospitals to deliver cost savings results and operational and strategic business insight. Kevin holds a Bachelor of Science degree in Business from the Kelley School of Business at Indiana University and was recognized as a Consulting Magazine “2019 Rising Stars of the Profession – Consulting’s 35 under the age of 35” award winner.
Prior to joining AArete, Jackie worked in Commercial Banking and Investment Banking spaces. She has consulted across a wide range of industries including Health: Payer, Financial Services, Retail and Consumer and Education and leads AArete’s strategy & operations. Her focus in the healthcare space is strategic advisory work, specifically with our Medicaid and Medicare clients. Jackie specializes in providing strategic profitability improvement solutions by conducting detailed spend analyses, market intelligence benchmarking, organizational assessments, developing process improvement plans and providing support in complex incumbent vendor negotiations. Jackie holds a Bachelor of Business Administration degree from Saint Mary’s College and has an Executive MBA degree from the University of Notre Dame. She is an active member of Women Business Leaders in the US Healthcare Industry (WBL) and is an Executive Sponsor of AArete’s Women’s Initiative Network (WIN) to further support the talent acquisition, development and retention of future female leaders at AArete.
Duane brings more than 25 years of consulting experience helping organizations in various stages of maturity and stability spanning from fast growth expansion to distressed environments. He leads AArete’s Health: Payer industry practice line by advising health plans, MCOs, administrators and other healthcare services organizations on a variety of performance improvement and operational initiatives. Duane holds a Masters of Business Administration degree from Northwestern University’s Kellogg School of Management and a Bachelor of Business Administration degree from The Ohio State University.
Madhav has been with AArete since foundation bringing over 20 years of experience in consulting across multiple industries. Over the past 10 years, he has led several large Health: Payer engagements in the areas of Cost of Care improvement, Fraud, Waste and Abuse (FWA), Targeted Ancillary Spend Review, Configuration Review and Pharmacy / Medical Crossover with a primary focus on over payment identification and recovery / reclamation. In addition, Madhav’s experience also includes the application of advanced data models to identify and score high risk members, leveraging Medical and Pharmacy claims data for risk stratification, care coordination and case management and designing and implementing customized Coordination of Benefits (COB) solutions. Madhav has also led several strategic profitability improvement and procurement turnkey engagements for clients in healthcare, financial services, professional services, manufacturing, law firms, media and entertainment and higher education. Madhav holds a Bachelor of Science degree from Nagarjuna University, a Master of Science degree from Osmania University and a Masters of Business Administration degree from Northwestern University’s Kellogg School of Management and is a member of the Institute of Supply Chain Management.
Katie brings more than 12 years of consulting experience specific to strategic profitability improvement efforts and procurement and operational improvement services including vendor management, SLA creation, procurement process redesign, organizational review and contract management. Katie holds a Master of Business Administration degree from the University of Notre Dame, a Bachelor of Business Administration degree from Saint Mary’s College and is also a Certified Public Accountant. Katie sits on the Board of Directors of Amandla Charter School in Chicago’s Englewood neighborhood and is an Executive Sponsor of AArete’s Women’s Initiative Network (WIN) to further support talent acquisition, development and retention of future female leaders.
With extensive expertise in data analytics and spend management, including strategic sourcing, vendor relationship management and demand management, Mark brings with him a broad toolset of strategic profitability improvement capabilities and is responsible for day-to-day project execution and client management. Mark holds a Master of Business Administration degree from Cornell University, a Bachelor of Arts degree from Washington University in St. Louis, and is a published author in CFO Magazine.
Prior to joining AArete, Paul began his career at Huron Consulting Group where he worked on corporate disputes and fraud investigations. With nearly 10 years of consulting experience across a variety of industries including extensive experience with healthcare payers, working with several large national payers, regional payers, and integrated health systems. He specializes in using data analytics to drive strategic decisions and operational improvements that result in significant bottom line improvement with minimal disruption to an organization. Paul directed and oversaw five engagements with state Medicaid Health Plans of 20M+ member payer that resulted in over $200M of savings and led an engagement with 4M+ member national Medicaid payer that achieved $25M of annual recurring savings through identification and implementation of unit cost, utilization management, and configuration opportunities. Paul holds a Bachelor of Science degree in Business Administration from Indiana University’s Kelley School of Business with concentrations in Business Economics & Public Policy and Finance and is a Certified Fraud Examiner (CFE).
Prior to joining AArete, Maria began her career at Arthur Andersen where she provided audit and consulting services to privately-held companies in a variety of industries including the transportation, professional services and non-profit sectors. She subsequently served as the CFO for a provider of global brand management solutions. With nearly twenty years of consulting experience, Maria is a leader in AArete’s Healthcare Payment Intelligence™ practice with a focus on configuration and overpayment analytics, including Healthcare Fraud, Waste and Abuse (FWA) and other payment integrity issues. She works closely with leading insurance payers to design and implement comprehensive solutions that are customized to align with each client’s unique business requirements resulting in the early detection, recovery and prevention of overpayments in healthcare claims. She couples her depth of business knowledge with her expertise in healthcare to create innovative solutions that are tailored to meet the challenges healthcare payers currently face. Maria holds a Bachelor of Business Administration degree from The University of Iowa, is a Certified Public Accountant (CPA) and belongs to the Illinois CPA Society. Additionally, Maria serves as President Elect of the University of Iowa Professional Accounting Council, is an Executive Sponsor of AArete’s Women’s Initiative Network (WIN) and is also a member of the Women Business Leaders (WBL) of the U.S. Health Care Industry Foundation.