The Challenge
Commercial – Network-Based, Analytics-Based
To improve competitiveness, a regional provider-owned health plan needed assistance with:
- Extending network access for its highly mobile membership
- Containing out-of-network medical cost
- Preserving its relationships and reputation with the local provider community
The Solution
Claritev structured a program combining national network access and provider-mindful reference-based pricing:
- PHCS Network accessed selectively within the provider system’s service area
- PHCS Network accessed nationally, outside the provider system’s home state
- Data iSight pricing for claims not contracted by the system or Claritev
The Results
Claritev helped the system improve its competitive position while continuing to keep community at its core:
- Savings generated on 98% of charges submitted
- 65% of savings with plan member protections
- 67% average reduction on claims not covered by networks
- 99% provider acceptance of reference-based pricing results
