MLR Optimization & Premium Enhancement

Services Focused on Decreasing Expenses, Improving the Health of Constituents, and Managing Risks

Catalyst has developed an integrated and coordinated portfolio of services that are customized and managed for each plan. Together, we propose to partner with you to pursue on-going improvements that will enable you to decrease your overall expenses, improve your constituents’ health, and manage financial and regulatory risks. Using an intelligent, data-driven design process we work with the plan to identify probable targets of improvements, including but not limited to:

MLR Reduction: Pharmacy, DME management, diagnostic imaging, and utilization management.

Premium Enhancement: Recoup any underpaid capitation, identify under/overpayments, and social security disability benefits identification.

Portfolio of Services

Home Care Ancillary Services

High Quality, High Touch Care

Our home care ancillary services cost reduction offering partners with health plans to provide their members with high quality, patient-centered, “high-touch” care through the coordination and management of home care ancillary services such as durable medical equipment and supplies, home health, home infusion, and post-acute transition of care.

Catalyst can help:

  • Significantly lower PMPM
  • Encounter reporting
  • Reduce fraud, waste and abuse
  • Improve provider contracting, reporting and scorecards
  • Electronic visit verification for home health providers
  • Improve care and effective utilization management

Pharmacy Cost Reduction

Eliminating Waste, Driving Savings


The focus of Catalyst’s specialty pharmacy cost reduction offering is on eliminating waste in both the pharmacy and medical benefits using state of the art technology designed specifically to reduce the high-cost pharmacy spend. Catalyst’s program uses place of service (home infusion vs infusion centers), prior authorizations, medical claims editing, and identification of duplicate claims, plus a fee schedule review to drive significant savings to the health plan.

Catalyst’s program provides:

  • High-cost injectable drug substitution for lower cost, equally effective drugs, while achieving significant cost reduction with excellent outcomes
  • Integration of pharmacy benefits and medical benefits
  • Analytics that incorporate business intelligence, intervention programs, and program monitoring

Member Disability Classification

Substantial Revenue Potential Realization


Catalyst’s disability identification and conversion offering assists in identification of Medicaid members who qualify for disability/ABD status, plus conversion of those members to a higher PMPM designation. This reclassification also allows for monthly income for the member and access to other programs.

Catalyst can:

  • Identify high-cost, chronically ill TNF/ACA expansion members
  • Reclassify those members to higher PMPM categories through federal and state programs
  • Connect members with programs that impact social, economic, and material factors surrounding their lives such as housing, education, availability of nutritious food, employment, and social support, all with significant impact on health outcomes

Payment & Premium Accuracy Optimization

Payment Integrity Solution


Catalyst’s payment integrity solution provides health plans with the ability to effectively coordinate benefits for Medicare members by significantly reducing overpayment of claims and limiting compliance risk with CMS. Catalyst helps identify Medicare entitled members that often go unidentified by using the mandatory insurer reporting under section 111 of the Medicare, Medicaid, and SCHIP Extension Act of 2007 (MMSEA).

Catalyst Can:

  • Recoup underpaid capitation and identify under/overpayments by focusing on Medicare secondary payment populations
  • Offer provider reconciliation solutions and methodologies to help payers navigate Medicare secondary payment populations and the associated capitated premiums paid by CMS
  • Limit compliance risk with CMS
  • Improve the accuracy of claims processing

Problem Solved

Business Process as a Service

Wood Wall

In addition to meeting the outsourcing needs of health plans, Catalyst can provide technology solutions that help meet your unique needs. Catalyst offers technologies for: claims, CRM, telephony (e.g., ACD, PBX, IVR, CTI and Workforce Manager), authorizations, analytics/reporting, enrollment, pricing, value-based payments.

When introducing new technology, Catalyst can take a modular approach to introducing a single aspect of a technology (i.e., a new claims engine). Using this approach, the you receive a new technology that helps improve your business and the effect is both less expensive and less disruptive to the business.

If you determine your current technology solution no longer meets your plan’s demands, Catalyst can introduce a comprehensive technology solution and lead the implementation. Given Catalyst’s wide range of partnerships and decades of experience, there’s no technology platform that Catalyst cannot install and manage.

BPO Optimization

Outsourcing business processes drives down administrative costs and allows you to focus on what you do best: enabling better healthcare outcomes.

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Operations Consulting

Catalyst can customize the right solution for your business to support cost avoidance and ensure compliance in our current ever changing landscape.

Explore Operations Consulting

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Strategic Consulting

Start with a focus on metrics, opportunities for cost reduction, and ways to gain efficiencies in the operations of a health plan.

Explore Strategic Consulting

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Technology Consulting

Using Data to Reduce Cost and Gain Efficiency

In the last decade, the healthcare market has been very dynamic. Not only have there been amazing technological breakthroughs, but there have been numerous mergers and acquisitions. Consequently, technology teams are faced with questions: How do we decrease my total cost of ownership? Why does it take so long to upgrade? What platform should we consolidate to or should we even consolidate? Why does it take so long to make a new product or get into a new market?