Medical Cost Management

We implement analytics and best practices to reduce fraud, waste, and abuse.

We create new levers and strengthen policies and processes to manage service and supply utilization.

We refine access to appropriate medications and high quality of care at the best price.

We optimize systems and processes to prevent diagnosis and coding gaps, enhance case management, and patient outreach and education.

A national payer was experiencing an increasing medical-cost trend, challenging investments in market-growth and quality initiatives. We launched a three-year transformation project, which resulted in a more than $6 billion run-rate impact over three years. To drive the change and portfolio ideation, we embedded experts and data scientists in the organization to develop analytics and tools for opportunity identification, which tools included clinical appropriateness “hot spotting” based on natural-language processing; automated, artificial-intelligence-based claim-auditing software; and proprietary and third-party clinical data sets paired with custom risk-adjustment methodologies.

A regional payer was seeking to align its medical policies with those of local peers to manage medical-cost trend better while reducing provider abrasion. We deployed an automated benchmarking capability that identified hundreds of medical-policy amendments, valued at 1.5 percent of medical-benefit expense, on day one.

A national payer in East Asia was experiencing an uptick in fraudulent claims, challenging its financial viability and the health of its members. In fewer than six months, we built and transferred an artificial-intelligence-based fraud-identification engine and redesigned the payer’s payment-integrity workflows and programs. The combination of efforts drove a 2 percent reduction in medical-benefit expense on a run-rate basis, with a fivefold improvement in auditing hit rates.