Reclaim Intro | Texas Medical Management
Reclaim Health
Created on October 21, 2024
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Transcript
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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
confidential
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.
confidential
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
confidential
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
confidential
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
confidential
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
confidential
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
confidential
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
confidential
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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- 1 -
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
confidential
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.
confidential
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