Health Care Reimbursement for Health Plans

The complexity of the health care reimbursement process is growing as the industry transitions to value-based payment models from fee-for-service medicine. With every new reimbursement scheme and benefits structure comes a new claims-processing challenge for your health plan. Our flexible and scalable reimbursement solutions enable your health plan to stay ahead of the curve by quickly adapting to new payment models, a more stringent regulatory environment and strengthening health care consumerism.

Our data-driven reimbursement technologies offer a full range of pricing, payment and claims-handling capabilities, allowing your health plan to automate, execute and scale complex mixes of value-based and fee-for-service reimbursement models. Built-in functionalities that adjust to your mix include authorization, medical appropriateness and diagnosis management tools that ensure payment approvals are based on clinical protocols and utilization management rules. Our technologies enhance the transparency of pricing, costs and reimbursement by accurately apportioning payment responsibilities by benefits level, enrollee or provider. Our solutions give you the ability to track utilization and payment incentives for narrow networks and alternative payment models. We also have solutions for pharmacy benefit managers, giving them real-time control over pharmacy claims management for the development of more efficient and profitable pharmacy benefit designs.

By simplifying the reimbursement process, we help you support transparency, increase engagement with providers and patients, ensure payment accuracy and drive down administrative costs, while at the same time improving the quality and safety of care for your members.