Case Study: Leveling the playing field

The Challenge

Commercial – Network-Based, Analytics-Based

To improve competitiveness, a regional provider-owned health plan needed assistance with:

• Extending network access for its highly mobile membership
• Containing out-of-network medical cost
• Preserving its relationships and reputation with the local provider community

The Solution

Claritev structured a program combining national network access and provider-mindful reference-based pricing:

• PHCS Network accessed selectively within the provider system’s service area
• PHCS Network accessed nationally, outside the provider system’s home state
• Data iSight pricing for claims not contracted by the system or Claritev

The Results

Claritev helped the system improve its competitive position while continuing to keep community at its core:

• Savings generated on 98% of charges submitted
• 65% of savings with plan member protections
• 67% average reduction on claims not covered by networks
• 99% provider acceptance of reference-based pricing results