Align holistic and integrated programs to segment and successfully serve high-cost members and manage high-cost claims efficiently and effectively
High-cost members and high-dollar claims drive a significant portion of spend and require a robust and purpose-built approach to manage.
A successful strategy requires deep understanding of the drivers behind this spend and aligning plan and provider interventions to address the most impactable utilization and members.
Identifying and segmenting high-cost members and high-dollar claims is critical to understand underlying cost drivers and application of the appropriate interventions and deployment of resources.
Common issues we help our clients solve
What is the quantified opportunity in medical cost savings from managing addressable high-cost members?
How do our high-cost member and high-dollar claims management capabilities compare to market best practice and where are there opportunities to improve?
What are the opportunities to monetize high-cost member and high-dollar claims management for ASO customers?
How can we integrate functions spanning high-cost member and high-cost claim management, Care Management, Utilization Management, Pharmacy, BH, and SDOH to drive the greatest medical cost savings potential?
Commercial vs. Medicare
Source: Oliver Wyman analysis
Source: Oliver Wyman analysis
Health Plans that are successful at managing high-cost members and high-dollar claims deploy a robust set of programs and services and purpose-built teams to manage each archetype.
Oliver Wyman has driven significant impact by helping plans create curated operating models integrating multiple functions to better manage high-cost member and high-dollar claims.
Created an integrated team to manage a subset of high-cost members and serve as an incubation unit to transform all of the plans’ Clinical Services functions (CM/UM/Pharmacy); enhanced clinical models to focus on collaboration between UM, CM and Medical Directors, continuity of care for the member, more frequent UM assessment, and rigorous discharge planning. Read more
Analyzed claims history across a multi-year period to segment high cost members and determined impactable spend and utilization. Read more
Designed a dedicated unit integrated within the Care Management team to review utilization history for high cost members and coordinate interventions for addressable utilization; defined tailored models for each LOB, outlined base and buy-up portfolio implications for Commercial ASO segment, and defined KPIs to measure value creation. Read more
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