Reclaim Intro | Texas Medical Management

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Proactively engage plan members to optimize their coverage and save on healthcare spend through Reclaim's AI-based, claims-driven healthcare advisory and advocacy platform.

Reclaim Health

CRO | Commercial leader

Scott Fillenworth

CTO | Tech leader

Chris Quirk

CEO, Board Director

Nataly Youssef

Chief Strategy Officer Health expert

Dogu Celebi

Board DirectorPartnerPillar VC

Jamie Goldstein

Chief Data Science Board DirecorAnalytics Chair at MIT

Dimitris Bertsimas

Board DirectorFormer COO CVS Health

Jon Roberts

VP Business Ops

Michele Lowe

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Reclaim's vision was created by a team of health, insurance, and technology experts who also happen to be patients and caregivers. We are empowered by software and algorithms designed and built by MIT researchers.

Reclaim was spun out of MIT with the purpose of helping families manage their healthcare dollars and optimize their health coverage.

STORY AND LEADERSHIP

on overall out of pocket cost including premiums and costs at the point of care.

to families with complex health visits.

$1,607 overspent

$1,900+ overbilled or owed

2024 Gallup and West Health

45% skipped care because of cost

2024 Gallup and West Health

1 in 2 struggled to pay for medical treatment

March 2024 KFF poll

3 in 4 worry about medical cost

landscape

Healthcare costs are the top concern for insured Americans, even outweighing worries about inflation and daily expenses.

[1] Aug 2024 Aon projections

[2] Employee Benefit News

[4] 2024 PwC’s Health Research Institute (HRI)

2x inflation rate.

+8% cost trend[4]

in wellness benefits specifically designed for cost containment.

33% engaged[2]

Employees tend to renew their existing plan, often lacking an understanding of their options and financial implications of them.

< 10% switch plans[3]

Self-funded employers spend more than $16K per employee per year on healthcare[1]. A 15K-employee group faces a $240M in annual healthcare spend.

landscape

[3] Aug 2024 SHRM

Medical costs continue to be a major concern for self-insured employers, with significant impact to their margins. Despite investing in benefits designed to mitigate rising cost, these benefits are often underutilized.

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Analytics insights

Coverage advisory

Billing advocacy

solution

Reclaim is an AI-powered healthcare advisory and advocacy platform helping employees and self-funded employers manage their health spend and optimize their benefits.

Proactive. AI-based.Claims-driven. Tech first, human supported.

Claims-driven billing, spend, underwriting and coverage insights

Itemized medical & Rx claims

AI-generated health event evaluation and bill savings

track every dollar

Bill corrections, reversals, and reimbursements

Simulation optimization personalizing recommendations

OPTIMIZE COVERAGE

Voluntary payouts, ancillary programs, network savings.

select right coverage

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Save $950 by switching to the low cost plan

simulation optimization recommending health coverage

AI-generated health events and bill savings

MEDICAL & RX CLAIMS DATA

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RECLAIM OVERVIEW

AI algorithms highlighting billing and/or adjudication errors given event context.

SAVING TRIGGERS

Uncover billing and adjudication errors

Collaborative filtering ALGORITHM predicting care needs over time

Incl. diagnosis, service, location, denial codes. Direct from carriers via data agreements.

In partnership with large employers, we ingest claims for all covered members, including 3-5 years of historicals and ongoing incremental data.

It all starts with the detailed medical and Rx claims data.

DATA INGEST

Detailed claims data

AI-DRIVEN

Contextualize claims bills into health events

Reclaim Health
Hospital stay amount reduced!

Now let's get your hospital coverage payout through your Securian Hospital Plan. I will get the process started for you.

save on bills

IMPACT ON EMPLOYEES

AI-generated health events and bill savings

24/7/365 Reclaim reviews all members' claims from the smallest to the largest and identifies overbilling cases.Reclaim human advocates proactively resolve the overbilling case on behalf of the member.

MEDICAL & RX CLAIMS DATA

Admitted to the hospital for sepsis and cellulitis

JAN 25 2024

Pain in left legEmergency visit

Reclaim uncovers adjudication error and the advocate takes action on behalf of the member.

mar 16 2024

Reclaim AI reviews the claims bills

The member receives an update from the advocate and a reduction in the amount owed.

Hi Taylor, Brenda here from Reclaim. I have some great news: your $3,770 appeal has been approved! Your recent hospital bill is now down to your $250 copay for St. Francis Hospital!

apr 10 2024

$3,770 saved through appeal

AI-powered healthcare financial advocacy platform.

OMG!! Thank you!!

IMPACT ON EMPLOYEES

save on bills - human Advocates

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AI-generated health events and bill savings

MEDICAL & RX CLAIMS DATA

Examples of prominent types of bill savings:

• Voluntary benefit payouts

• Bill corrections

• Reimbursements by providers for reversed claim charges

Reclaim Health
Hospital payout has been approved!

Hi Taylor, Brenda here again from Reclaim. I have more great news: your $1,200 hospital payout has been approved! The funds should show up directly in your bank account within 5 business days. Tap here to chat if you have questions!

Oh my absolute pleasure! I am working on reviewing the services billed by Dr. Johnson for your March 5th visit. Some of the charges were recently reversed by your insurance. I will get back to you shortly with an update.

$1,960 average employee bill savings per employee for qualifying events.

Thank you so much!!

IMPACT ON EMPLOYEES

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AI-generated health events and bill savings

MEDICAL & RX CLAIMS DATA

Reclaim proactively reviews the user's healthcare bills and highlights ways they can save on cost.

save on bills

IMPACT ON EMPLOYEES

OPTIMIZE coverage

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AI-generated health events and bill savings

MEDICAL & RX CLAIMS DATA

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OPTION 2

OPTION 1

Simulation optimization computes out of pocket cost for utilization scenarios across distribution of similar patients.

SIMULation optimization

Optimize recommendations and minimize financial risk

Collaborative filtering ALGORITHM predicting care needs over time

Takes attributes of recent events as features. ML yields distribution of evolving care needs.

COLLABORATIVE FILTERING

Match to people with similar health events

AI proactively recommends actions through the lens of people like me.

IMPACT ON EMPLOYEES

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60.1% of engaged employees adopt Reclaim's recommendations.$753 in average employee savings.

OPTIMIZE coverage

AI-generated health events and bill savings

Reclaim personalizes recommendations in the context of the member's own recent health visits.

MEDICAL & RX CLAIMS DATA

Collaborative filtering ALGORITHM predicting care needs over time

IMPACT ON EMPLOYERS

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High activation rates unlock our proactive engagement throughout the year.

Reclaim is offered to ALL plan members. Reclaim accesses employees across patient cohorts, demographic segments, and coverage needs.

78.8% of employees activated Reclaim across all groups (new or existing).

High activation rates

IMPACT ON EMPLOYERS

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Reclaim Health
Get started with Livongo today

Hi Taylor, we reviewed your bill for your Aug 5 visit. No charges other than your copay. Tap here to review the details and get started on a personalized action plan with Livongo, completely free of charge to you.

Reclaim proactively engages members throughout the year in the context of their own claims/bills, highlighting voluntary payouts, care management programs, and other ancillary programs and network considerations.

Of those activated, 70.5% employees proactively engaged throughout the year in the context of their bills.

High engagement rates

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• For network-efficient plans (tiered, reference-based), 6x increase in adoption, with 95.6% retention rate

• Proactively linking employees to chronic condition management programs in the context of their bills. For example: 78% of employees with diabetes 80% with asthma.

IMPACT ON EMPLOYERS

Employers see an 87% increase in cost-effective plan adoption

Improved Benefit Utilization

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Real-time access to activation and engagement insights and actionable targeted member communications.

Optimize member communications informed by actionable savings opportunities.

impact on Employers

Targeted Communications

impact on employers

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Integrating detailed claims data for all of your members, including sub-cohorts. Reclaim provides insights and sensitivity analysis. You can simulate product-member fit and tailor your benefit offerings.

Simulate your healthcare benefitdesign based on plan members' specific needs.

Simulate Benefit Strategies

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79.4% of employees activated at open enrollment in partnership with the benefit administrator.

pre-oe simulations

Given the membership claims data and benefit design features, Reclaim conducted a simulation of its benefit recommendations before launch.

RBP plan retention rate for activated employees vs 84.8% for those yet to activate Reclaim.

95.6%

RBP plan adoption 2 weeks after rollout.

2.68x

36.8%

14.4%

2024 RBP plan adoption

Reclaim Impact

2023 RBP plan adoption

personalized Employee Cost Estimates

Matching members to patients like them, employees review their likely out of pocket costs for all eligible plans before finalizing their benefit elections.

current plan review

Employees review their recent bills and their current plan performance, helping them understand whether they are overinsured, underinsured or well insured.

employee activation

In partnership with the benefit administrator, Reclaim ingested employee plan eligibility. At open enrollment, Reclaim activated employees with a simple prompt.

detailed claims data

After launching with Reclaim at open enrollment, Reclaim increased RBP plan adoption among activated employees by 2.68x. RBP plan adoption increased from 14.4% to 36.8%.

outcomes & impact

Claims data elements →

Activation at open enrollment →

Partnering with the group health plan, Reclaim analyzed both historical and current healthcare claims data for all covered members across three different carriers.

Ahead of its 2024 open enrollment season, the company sought a solution to boost RBP plan adoption. The company identified Reclaim's claims-driven healthcare financial advocacy platform as a unique value proposition. Reclaim's platform empowers employees to better understand their plan options and the impact on out of pocket expenses, all within the context of their own care needs.

solution

A leading commercial and residential services company struggled to achieve desirable adoption rates of a dozen reference-base pricing (RBP) plans designed to contain cost for both the employer and their employees in 2023. Despite running an extensive communication campaigns during their 2023 open enrollment, only 14.4% of the employees choose these plans.

challenge.

case study

Review your recent bills and your current plan cost before enrolling in next year's coverage.

How a leading services company with over 20,000 employees increased the adoption of its newly offered reference-base pricing plans by 2.68x.

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70% of employees accepted our recommendations.

2.79%

11.57%

Activated and engaged

Not yet activated

Medical cost trend (%)

The results evidently demonstrate Reclaim's effectiveness in driving cost savings and employee participation.

Most importantly, engaged employees exhibited a significantly lower year-over-year overall cost trend compared to those who were not activated.

Significant lower cost trend

in overall cost (premiums and out-of-pocket expenses) for engaged employees.

$523

saved per bill qualified for overcharge resolution or voluntary payouts, on average.

$1,123

Significant employee savings

39.7%

59.8%

HSA plan adoption 3 years after Reclaim rollout

HSA plan adoption before Reclaim rollout

Increased HSA plan adoption

Activation was also high among employees with chronic illnesses - 85.6% for diabetics and 90.7% for asthmatics.

Remarkable activation rate

The overall activation rate reached an remarkable 87.1%

After implementing Reclaim’s financial advocacy platform for over three years, the employer achieved significant increases in employee adoption and engagement with cost-effective health plans and supplemental benefits.

outcomes & impact

optimize coverage year-over-year

In the context of their recent bills, employees review their current plan performance, and compare cost and care access implications if they were to consider switching to a more cost effective coverage option.

personalized recommendations

proactive advocacy and savings

Reclaim proactively reviews the user's healthcare bills and highlights ways they can save on cost by taking advantage of their benefits and coverage.

employee activation

In partnership with the benefit administrator, Reclaim ingested employee plan eligibility. At open enrollment, Reclaim activated employees with a simple prompt.

The plans and benefits work. Find a way to increase adoption and engagement.

Employees who activated Reclaim saw substantial out-of-pocket savings, and overall medical costs were notably lower among those engaged with the platform.

To address low adoption and engagement with their innovative health plans, the employer turned to Reclaim's financial advocacy platform. Reclaim proactively engages employees by leveraging their personal healthcare data, ensuring they fully utilize the benefits designed to deliver significant cost savings for both employees and the employer.

solution

The employer has introduced innovative health plan designs and supplemental benefits that have been proven to control medical costs and generate significant savings for both employees and employers. However, adoption and engagement with these benefits have been disappointingly low. This lack of participation is preventing both employers and employees from realizing the substantial cost savings that these plans are designed to deliver.

challenge

case study

A leading consulting firm with 15,000 employees has successfully curbed rising medical costs by increasing the adoption and utilization of cost-effective health plans and ancillary benefits.

Employees review their recent bills, their current plan performance, and their personalized likely out of pocket costs before finalizing their elections.

Over 3 years, adoption of HSA plans increased by 58.5%, driven by high engagement rates across all employees.

Light integration with benefit admin collecting consent at enrollment.

• Easy rollout for employers,
• High activation rates; and
• Proactive consent for Reclaim to review and take action on past and future bills on behalf of employee and their dependents.

Activation while enrolling in benefits yields 78.8% activation rates across our groups.

Activation at OE

Billed charges, covered charges, copay, deductible, coinsurance, reversed charges, denials and their codes

Billing and rendering provider national identifiers, their specialties and primary care indicators.

~50+ location and network codes, incl. inpatient, observation, urgent, emergency, and others.

~25,000+ service codes (CPT, HCPCS, Revenue), incl. screening, diagnosis, and treatment services.

~70,000+ ICD 10 and DRG diagnosis codes, incl. diagnosis severity and injury situational details.

Best known as UB04 (hospital claims) and HCFA 1500 (professional claims).

• Existing data use agreements with all national payors, multiple regional payors and claims administrators.

• We follow the lead of our employer clients and expand our data use agreements with new TPAs as needed.

Reclaim receives detailed claim line by claim line information.

Claims data elements