Coverage & Reimbursement Guideline Analysis

Solutions to improve a health plan's success

a pair of glasses on a table

We work with health plans to ensure medical and reimbursement policies are designed in a manner which reflects the overall intent of the plan's benefit design. With value-based care initiatives driving the need to reduce costs while improving the quality of care, benefit design and coverage criteria is a key factor to a health plan's success.

We understand the impacts of healthcare reform and the shift from traditional fee-for-service payment models to value-based care. We assist payers in evaluating coverage and reimbursement guidelines to ensure compliance with benefit design, Affordable Care Act and other related regulatory requirements, as well as maintaining parity with competitor's products in the insurance marketplace.

Independent & Objective Assessments

In addition to aiding in the development of new policy guidelines, we can also provide independent and objective assessment of existing product line performance and operations for optimization. Our experienced professionals have conducted analyses of medical and reimbursement policies to identify gaps in existing coverage guidelines and identify opportunities to add or revise criteria to provide greater clarity on medical necessity determinations, including clinical criteria, frequency, dosing and duration limitations.

We collaborate with clients to deploy solutions and initiatives that have positive financial impact while improving the overall quality of care. Our consultants provide deep insights that reveal opportunities, define strategies, guide your decision-making and implement meaningful change.