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