Health Plan Solutions

Customers and program sponsors demand better quality and more cost-effective healthcare. As such, health plans must strategically adopt and scale networks while evolving the way they collaborate with internal and external stakeholders (e.g., healthcare providers, consumers and regulators). Network management strategies including comprehensive data management, proactive regulatory compliance, integration of risk management functions, early and ongoing engagement of internal audit, digital transformation and advancing value-based care programs are key to successful network optimization. 

Baker Tilly’s health plan solutions can help create effective and compliant network management strategies that mitigate risk, increase operational efficiencies and outpace the competition.  

Learn more about health plan network management

The adoption of value-based care (VBC) solutions is a strategic imperative for health plans today and can create transformational impacts, but often require significant changes to provider relationships, care delivery and payment models. Health plans must increase collaboration among stakeholders and establish new capabilities across people, process, and technology to achieve the goals of their VBC models such as improved health outcomes, quality of care and increased cost-efficiency. 

Baker Tilly’s payment transformation framework can help your organization navigate the end-to-end complexities involved in operationalizing value-based care models, from current state feasibility assessments to creating program monitoring structures necessary to scale program successes. 

Check out our case study to see how a large multistate health plan enabled performance.

Digital transformation efforts lead to benefits such as improving the accuracy of a health plan’s operations, improving stakeholder trust in technology investments and creating lasting impacts to member health outcomes via reduced care gaps, identification of new opportunities for care coordination and more.  

Connectivity between data, systems and insights can be transformative for an organization, but updating legacy platforms and integrating advanced technologies can be challenging. Our health plan solutions help guide your team with a structured approach to enable organizational change, streamline operations and drive greater return from achieving your digital transformation goals. 

View our practical value based care data management guide for health plans as well as our case study about how dental insurance network expanded their geographic footprint and take on new customers.

Health plans must navigate a complex and evolving regulatory landscape, while constantly burdened with risks that can threaten an organization’s bottom line, expose it to potential government sanctions, HIPPA violations and cybersecurity schemes. Health plans must juggle No Surprises Act (NSA) compliance, adherence to additional interoperability requirements (e.g., CMS Interoperability and Prior Authorization Final Rule), and multiple state regulations, by leveraging strategies that are accurate and defensible during audit to ensure compliance and minimize the risks of large fines and/or reputational damage.  

Explore health plan solutions that can help your organization create a strategic, proactive process to reduce inherent risks while maintaining compliance. 

Dive into our case study about how a health plan achieved interoperability compliance through cloud implementation

The health insurance industry continues to explore specific AI use cases such as reducing fraud, efficiently processing claims, improving patient care services and examining the potential for AI to predict future healthcare needs, coverage determinations as well as treatment outcomes. As workforce shortages continue to impact health plan member’s access to quality care, AI can offer health plans many benefits such as the reduction of manual processes, support in claims editing and more accurate pricing.  

The task of identifying and assessing risks that could arise specifically from AI technologies intersection with the healthcare industry is not trivial. Our health plan solutions can help your organization navigate the AI landscape from AI readiness to governance, benefits and risks included. 

Explore our AI readiness checklist and how AI is revolutionizing the healthcare and life sciences industry