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Payment integrity
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Medical Cost Management

Strengthening medical-cost portfolios, with the triple aim of improving healthcare affordability, access, and quality

What we do

Payment integrity to safeguard patients and other stakeholders

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

Appropriate services for patients

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

Pharmacy-value-chain optimization

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

Care gaps and opportunities for heightened risk accuracy

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

>$4.4B

in run-rate savings

across our clients served from stemming fraud, waste, and abuse

1–3%

improvement

in bottom line

6%

reduction

in patient-readmission rates

Featured capabilities

We invest heavily in developing proprietary tools, databases, and methods.

RTS: Through RTS, a special unit of McKinsey, we deliver a proven approach for transformational change to clients seeking radical, rapid, and sustainable performance improvement.

Payment-integrity artificial intelligence: Our payment-integrity solution uses proprietary analytics to enable deeper discovery of fraud, waste, and abuse.

Fraud, waste, and abuse concept library: Our library of thousands of automated payment integrity and medical management initiatives identifies immediate business value while reflecting proven implementation methods.

AI-based clinical decision support: Raise care quality and consistency and reduce lead times in your case management, care management, prior authorization, and appeals and grievances processes with our clinically-trained algorithms.

Clinical-concept benchmarking: We identify opportunity hot spots through a benchmarking solution built on our proprietary grouping methodology and designed to maximize clinical understanding and fit.

Policy benchmarking: Our policy-benchmarking solution compares variations between an organization’s policies and those of its peers to identify opportunities for collaboration to drive improved clinical outcomes for patients.

Examples of our work

Portfolio ideation

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.

Medical-cost management

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.

Reduction of fraudulent claims

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.

Featured insight

Article

Using machine learning to unlock value across the healthcare value chain

– Machine learning is transforming the healthcare industry by changing the way care is delivered, and its impact is poised to increase.

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