Clinical management

Develop integrated, comprehensive strategies to address cost, quality and revenue.

Environmental forces are combining to cause major changes in the health industry. Health care delivery and payment models are dramatically changing and information and data are becoming increasingly available. Chronic disease incidence is reaching epidemic proportions and the number of people in the health care system is increasing as a result of the Accountable Care Act.

Together, these forces will push health plans past the point of incremental change and into new business models and capabilities centered on comprehensive care of their member populations and more effective management of provider networks. Health plans must prioritize foundational clinical capabilities as part of their goal to provide the best care to members, strengthen provider relationships, and drive overall plan performance. Plan capabilities must span six core areas:

  • Provider network effectiveness
  • Expanded network to meet specialized areas of care
  • Information-powered clinical decision making
  • Integrated member services and care management
  • Quality improvement
  • Risk-based reimbursement

Optum supports these areas with comprehensive solutions. We help positively affect health outcomes by matching interventions and provider networks to each member’s needs. The result: improved quality, utilization, and risk-based reimbursement.

Clinical Analytics

Utilize member data to proactively identify opportunities to reduce costs

With new benefit mandates, Medical Loss Ratio (MLR) regulations, and population shifts, it is more critical than ever for health plans to access and analyze member information. Data such as a member’s health status, the value delivered through networks, and the performance of clinical management programs helps everyone deliver the best care possible. Access and evaluation of clinical information helps identify trends in utilization, disease prevalence, and their related costs.

Specialty Networks

Extend current provider networks to effectively meet the needs of members who require specialty areas of care

The price tag to treat certain conditions can be staggering. A relatively small number of medical conditions account for a disproportionate share of treatment spend. Health plans’ traditional networks are not equipped to provide care to people with this type of specialized need. At Optum, we build integrated systems of care focused on specialty areas that complement existing networks and medical programs.

Provider Network and Data Management

Efficiently manage network contract information and accurately price claims

Networks are one of the greatest assets a health plan has. Networks serve as the primary point of connection with customers and are one of the primary determinants of cost of services covered. As a result, health plans must focus on the quality of their networks and actively pursue strategies for ongoing improvement.

Manage all aspects of a provider network in a single provider source of truth — from adequacy to recruitment and product, to contract and distribution. Our solution:

  • Performs in-depth review of existing networks and assists in the creation of new networks (geographic, narrow, etc)
  • Efficiently maintains aligned, accurate provider information for directories, fee schedules and other applications
  • Enables new, multi-tiered pricing structures and aligns contracts, fee schedules and data
  • Initiates and tracks credentialing and recruitment processes
  • Accurately models contracts and reimbursement
  • Meets new and future compliance requirements cost effectively and on-time

Optum offers provider data management services that meet key provider network administration challenges, helping to enable:

  • A single view of all aspects of a provider for the organization
  • Real-time analytics against the source of truth
  • Streamlined implementation of new network strategies
  • Lower administrative costs
  • Improved claims payment accuracy and automation
  • Integration with existing processes and systems


Improve quality measure performance

Rising medical costs, affordability pressure, new reimbursement models, increased regulatory requirements, and public reporting of quality metrics, have shifted how plans view the importance of a quality focus. As a result, plans today focus on:

Risk Adjustment

Ensure reimbursement for Medicare, Medicaid, and individual membership

To prepare for population shifts caused by the Accountable Care Act provisions, plans will need to develop strategies that assess financial exposure and estimate risk-based reimbursement. Plans may find it challenging to predict how much health care will cost for newly insured members, which makes the task of mitigating those costs even more difficult.

Member Engagement and Care Programs

There is growing evidence that an integrated, population-based health management approach empowers people to live healthier lives. Health management also decreases avoidable chronic complications and reduces health care costs.

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