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Healthcare Payer Strategic Roadmap

One of the Midwest’s largest and most established healthcare payers needed to position themselves to effectively manage a number of changes that were taking place in both their industry and their local market.


These changes included the impending impact of Health Care Reform, an aging and sicker population, the erosion of the southeast Michigan employer base, and increased pressure from national carriers.

The Challenge

Assist the organization’s leadership to make solid, fact-based decisions in a very fluid market situation.  This would include a robust analytics capability to assist with critical decision support in: Claims; Employer Groups; and Care Management.

Strategy and Goals

Utilizing a mixture of one-on-one interviews with senior executives, workshops, comparative analysis to best practices, and weighting techniques, RCG Collected, Analyzed and Categorized key business drivers.

Some of these business drivers included:

  • Growth
    • Product Diversification
    • Geographic Expansion
  • Health Status Improvement
  • Health Care Reform

Through the use of facilitated workshops, these drivers were then used to identify and document future state business requirements including:

  • Embed analytics into the claims operation
  • Expand employer group analysis capability
  • Enable efficacy analysis of care management initiatives
  • Measure the effectiveness of care management initiatives

These requirements were then compared with current state capabilities and processes and gaps were categorized into logical groupings. These groupings subsequently formed the foundation for identifying and prioritizing the future strategic initiatives that were depicted on a Business Intelligence Prioritization Matrix.

The Final Results

  • Improve claims payment policy compliance
  • Reduce the time needed to identify fraudulent claims
  • Significantly reduce medical cost
  • Improve employer group transparency
  • Reduce response time on fulfillment of employer group report requests
  • Provide analytics to support new product creation
  • Reduce cycle time for medical cost, budget, and forecast variance analysis
  • Enhance the company’s ability to produce accurate medical cost forecast scenarios
  • Improve the ability to monitor and manage provider performance compared to contract incentives
  • Increase the effectiveness of provider relationship management
  • Optimize the performance of the medical program portfolio based on ROI and member health improvement.

The Conclusion

RCG was engaged to provide a short and long-range road map that identified critical business drivers and detailed the necessary steps to increase the organization’s ability to quickly make decisions in this changing landscape.


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Strategy & Roadmap

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