Financial and organizational consulting for payers

By combining our diverse healthcare skills and expertise, the CGI team has developed integrated solutions to complex challenges that your organization faces to ensure compliance and control costs. CGI’s ability to analyze and model data, coupled with unsurpassed consulting knowledge, has allowed us to consistently provide results to clients.

Some of service offerings include:

Payment methodology design and implementation

To help control increasing inpatient, outpatient and professional claim costs, CGI offers comprehensive reimbursement methodology consulting and software. The CGI team of healthcare insurance and information systems consultants has extensive experience in the evaluation, design and implementation of reimbursement strategies. Our experts have successfully worked on such solutions as APCs, APGs, ASCs, DRGs, Per Diem, Fee Schedule and RBRVS.

Our strength is our ability to understand the impact these types of changes will have on your business. Our experience and programs address everything from training and education, to financial model development, to information system changes, to provider contracting and relations and beyond. The ability to understand all of these areas of your business and to work with you to implement a comprehensive and integrated solution to the challenges associated with a fundamental shift in operating your business is crucial to ensuring your future success.

APC assessment and implementation

Leveraging off of the implementation of APCs by the Medicare program, healthcare payers can provide valuable benefits to both themselves and their providers. Strange as it may sound, we find that many providers often welcome the implementation of a standardized billing and reimbursement mechanism between their Medicare business and commercial business. It can also provide the health plan with the ability to control, monitor, track and negotiate effective and fair contracts with providers.

At CGI, we have implemented prospective payment systems of all types for many years. As a result of this experience, we can work with your plan to conduct a high-level assessment of the potential impact of an APC implementation, and then turn that into a full-scale implementation plan if desired.

Financial audits and recoveries

The process of paying claims successfully depends upon the speed, accuracy and dependability of payers’ claims processing system. Sometimes incorrect information, manual overrides and a need to push claims through the system can result in claims that are overpaid in error. At CGI, with the use of our financial recovery services, proprietary software tools and other techniques and methodologies, our team can identify and investigate claims with potential overpayment due to adjudication system processing errors. Retrospective review of claims allows you to perform a root cause analysis to examine historical performance of your claims processing system and to alleviate overpayments on a go-forward basis.

Data mining

CGI’s analysis tools, knowledge of the healthcare industry, extensive data experience and problem solving background gives it the unique ability to solve many healthcare issues and questions using your robust data marts. Our expert team will unlock the mysteries in your mountains of data quickly and efficiently to help reduce medical and administrative expenses.

Our data mining activities often lead to extensive and significant changes to your business processes, resulting in additional medical and administrative cost savings. Examples of some of successful business process re-engineering efforts we have undertaken include:

• Pended and rejected claims review
• Utilization management and claims payment policy review
• Health plan versus national standards policy review and assessments

Cost containment methodologies

Health payers need to ensure that medical and administrative expenses are tightly controlled. CGI experts have developed a number of strategies to accomplish that mission both in the short and long term. From an initial cost containment assessment to a root cause analysis, CGI has developed an expansive list of cost containment methodologies that can truly impact your plan’s bottom line.

Actuarial services

CGI has earned a reputation for performing timely and cost-effective actuarial services by offering a unique combination of expertise in actuarial benefits analysis, managed care analysis and calculations of health reserves for insurers and self-funded plans.

Medicare, Medicare+Choice, and Medicaid

Our compliance and regulatory experts work closely with your staff to evaluate your financial, operational, contractual, medical, sales and service performance with the objectives of improving quality, increasing productivity, reducing costs and ensuring compliance with state and federal regulations.

Provider contracting

A leader in the healthcare finance and compliance area, CGI has substantial experience developing and implementing new payment methodologies and ensuring compliance with existing payment and regulatory requirements. We have assisted clients with HIPAA, Medicare, Medicaid and M+C compliance issues.

Cost containment methodologies

CGI recommends strategies to help payers maintain tight control of medical and administrative expenses and to establish effective methods for cost containment and improved efficiency. Our cost containment services cover a number of areas. They include: medical expense cost containment, provider contracting services, root cause analysis, new product development, administrative expense cost containment, financial recoveries and audit, provider audit and pharmacy.

Strategic planning and organizational consulting

CGI's organizational consulting experts work with executive teams of healthcare organizations in times of growth, transition, and crisis to improve their position in the marketplace. Our services include short- and long-term strategic planning, business plan development, marketing and strategic communications, crisis consulting, turnaround services and litigation support.