Optimizing Health Plan Operations with Strategic Advisory Services

Transforming Core Administration for Health Plans

Health plans often struggle with outdated legacy systems, inefficient workflows, and fragmented vendor ecosystems that drive up costs and limit scalability. Our Advisory Services help payers modernize their core administrative functions, optimize performance, and reduce their Total Cost of Ownership (TCO). Our team doesn’t just identify problems; we assess every aspect of your operations, from claims processing and member services to compliance and financial performance. Once we identify opportunities for cost savings and efficiency gains, we deliver tailored solutions powered by AI to drive quicker, measurable results. 

Key Advisory Services for Core Administration:

• Core Administration Performance and TCO Assessment  
  A thorough evaluation of administrative functions to determine performance gaps and uncover cost-saving opportunities

• Operational Readiness Assessment 
  Analysis of payer business and technology operational preparedness to ensure successful implementation of new programs, systems, and processes with minimal disruption

• Ecosystem Blueprint and Design 
  Strategic analysis of payer core administration systems to provide roadmap to a modernized cloud based connected ecosystem to enhance integration, scalability, and efficiency

• Program Health Check for Implementation 
  Identifying risks and gaps in ongoing implementation processes to ensure smooth project execution 

Enhancing Risk Adjustment Strategies

We provide data-driven risk adjustment performance analysis laser focused on claims processing, CMS submissions and retrospective medical record retrieval and coding practices. Our expert consultants work closely with your subject matter experts to identify opportunities for improvement.

Key Risk Adjustment Advisory Services:

• Retrospective Coding Accuracy and Documentation Support 
  A detailed review of coding guidelines, retrieval and coding processes, and sample audits of previous retrospectively coded medical records to ensure accurate, complete, and compliant ICD-10 HCC coding, followed by best practice recommendations to optimize documentation and data collection for accurate risk scoring

• Risk Score and Reimbursement Optimization 
  Exploratory analysis of current claims, submission processes, and HCC code capture methods—modeling lost opportunities through supplemental data sources and estimating the associated financial impact—to deliver targeted recommendations that improve risk adjustment performance

• Regulatory Compliance and Best Practices 
  Ensuring adherence to evolving regulations while enhancing operational efficiency 

Why Choose UST HealthProof Advisory Services?

• Industry Expertise 
  Our team consists of healthcare professionals, technical subject matter experts, coders, auditors, and compliance experts with deep industry knowledge

• Proven Results 
  We help health plans improve operational efficiency, reduce costs, and enhance regulatory compliance

• Customized Approach< 
  Every health plan is unique, and we tailor our solutions to meet your specific challenges and objectives

• Long-Term Support 
  Beyond one-time assessments, we provide ongoing guidance to ensure sustainable success 

Driving Value Through Informed Decision-Making

Health plans focused only on short-term cost reductions often face higher long-term expenses due to inefficiencies, hidden fees, and compliance risks. By leveraging our advisory services, insurers can gain a clearer understanding of their operational landscape, mitigate risks, and implement best-in-class solutions that drive sustainable growth.

At UST HealthProof, we help health plans turn operational challenges into opportunities. Contact us today to learn how our advisory services can optimize your health plan’s efficiency, compliance, and financial performance.