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Case Study: Leveling the playing field

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, and preserving its relationships and reputation with the local provider community.

May 15, 2019 |
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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
Read the Case Study of how a regional provider-owned health plan saved with Claritev.

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  • Your team is great at building trust. I have had nothing but a positive and efficient experience.

    Manager

    Large Midwest health plan

  • These are really important things that we wouldn’t be able to do without a partner like Claritev because, again, we want to look at this stuff holistically across carriers. It would take me four times as long to go into every health plan and do this kind of analysis.

    Executive Vice President

    Large, regional consulting firm/insurance brokerage

  • They (Claritev) are continuously refining and developing the platform to meet my needs.

    A Major Healthcare Provider

  • The Technology Leadership Program has brought my department tremendous value. The well-structured program offers the talented hardworking associates options for their career paths, yet exposes them to high visibility initiatives. Every associate has brought a unique perspective and strong professional skills to the organization.

    Bobby Vincent

    Senior Information Technology Director

  • The Technology Leadership Program associates have a tremendous opportunity before them. To have three years to rotate through various departments within Information Technology before deciding which role/area suits them best.  Depending on their choice and interest, they become a unique blend of technologist, business expert and, eventually, corporate leader.

    Andrew George

    Senior Vice President, Information Technology

  • One of the great successes of the program has been our ability to identify and develop emerging leaders whom contribute in every facet of our business. It hasn’t been just about growing IT leaders, it’s about maturing business leaders for Claritev.

    Ed Ververs

    Senior Director, Telecom & Data Center Management

  • I had the privilege to mentor some of the Technology Leadership Program participants and was fortunate to absorb a member into my team, where he has helped tremendously with new automation techniques. Participants bring in fresh perspectives and extreme enthusiasm to IT here at Claritev. I’m looking forward to adding more.

    Vasu Raghunathan

    Senior Director of Data & Service Delivery

  • You have been a great partner from day one. You collaborate with us until we find a resolution. We look forward to a long-standing partnership.

    Payment Integrity and Performance Manager

  • The things we value most about our partnership with Claritev are not just the reliable, efficient delivery of savings through their MSP and ESRD services, but the fact that they are always willing to come to the table to discuss and collaborate on new and innovative solutions that nobody else in the industry has yet to try.

    Drew Satriano, VP of Payment Integrity

    Highmark, Inc.

  • In our experience, Claritev has been very responsive with great turnaround times and the findings they’ve presented to SIHO have been accurate and reasonable.

    Claims Department

    SIHO Insurance Services, Inc.

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