Performance Optimization

Bringing excellence to every aspect of your implementation from enrollment to claims payment

The growing competition amongst plans in government programs places an increased emphasis on plan performance and requires that health plans create differentiation within the market as they compete for enrollment and meet margin goals. Plans must continue to demonstrate improvement across the entire spectrum of plan operations including revenue, medical loss ratio, product performance, compliance, and network.

At GHG, we work with plan leaders to identify and prioritize the key initiatives that will drive critical performance improvement. Our subject matter experts enable plans to create tactical strategies to grow revenue, manage costs, maintain compliance, and improve the quality of care for your beneficiaries.

Services include:

Medical Loss Ratio

For many plans, one of the most significant performance metrics is the Medical Loss Ratio (MLR). MLR provisions can vary by line of business and can have a significant impact on a plan’s ability to deliver high-quality care and meet margin goals. Plans must have the ability to accurately project and predict MLR throughout the year and have strategies in place to take action if they are not meeting MLR targets. GHG can help identify key MLR cost drivers and ensure that your providers and provider network are aligned to deliver the highest level of quality care to your beneficiaries.

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Risk Adjustment

Once a product strategy is established, the conversation must turn to benefits. Smart benefit design is a dynamic process that begins with an examination of intended markets with consideration given to strengths in member retention and medical management, and is executed with specific enrollment and financial targets in mind. Whether your organization is just entering the government programs space or is already well-established, our team is standing by to assist.

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Risk Adjustment

Health plans that offer Medicare Advantage, ACA, or Medicaid Managed Care products rely on risk adjustment to ensure they receive the most accurate premium reimbursement that reflects the true illness burden of their beneficiaries. A comprehensive risk adjustment strategy utilizes both prospective and retrospective programs enabled by comprehensive analytics and targeting methods. Plans must also ensure the completeness of their risk adjustment data submissions by understanding the entire end-to-end data supply chain. GHG’s risk adjustment experts can identify opportunities for performance improvement and help your plan drive risk score accuracy.

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Operational Excellence

Operational inefficiencies can wreak havoc throughout an organization and have the potential to create significant compliance issues. Whether it be outdated processes or systems, cross-functional breakdown, resource constraints, identifying the true root cause is critical to mapping a future state solution. At GHG, our team of experienced subject matter experts can work with your plan discover complex pain points and effectively implement a path to resolve them while minimizing the disruption to your members and business.

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Product Improvement

Once a product strategy is established, the conversation must turn to benefits. Smart benefit design is a dynamic process that begins with an examination of intended markets with consideration given to strengths in member retention and medical management, and is executed with specific enrollment and financial targets in mind. Whether your organization is just entering the government programs space or is already well-established, our team is standing by to assist.

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Product Improvement

Once a product strategy is established, the conversation must turn to benefits. Smart benefit design is a dynamic process that begins with an examination of intended markets with consideration given to strengths in member retention and medical management, and is executed with specific enrollment and financial targets in mind. Whether your organization is just entering the government programs space or is already well-established, our team is standing by to assist.

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Network Improvement

In today’s marketplace, a network must be robust and marketable. GHG can provide you with an in-depth analysis of your plan’s status against current CMS requirements, identify areas of concern, and uncover opportunities for growth. We can also help you develop the oversight and monitoring P&Ps needed to address evolving network and directory requirements. These strategies will be paramount in putting you ahead of your competition.

 

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Compliance

Once a product strategy is established, the conversation must turn to benefits. Smart benefit design is a dynamic process that begins with an examination of intended markets with consideration given to strengths in member retention and medical management, and is executed with specific enrollment and financial targets in mind. Whether your organization is just entering the government programs space or is already well-established, our team is standing by to assist.

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Compliance

Compliance permeates every department within an organization. Cross-functional relationships and diligent oversight, both internally and with vendors, are critical in maintaining a proactive approach to compliance. Learn how GHG’s team of compliance experts can help your plan develop early warning systems to ensure that operational inefficiencies and threats are identified immediately and have a limited impact on member experience, business performance, and potential growth opportunities.

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