Premium Integrity

Premium Integrity Success Story


A large, multi-state Medicare Advantage Organization (MAO) engaged Pareto to perform a 6-year evaluation of MA premium accuracy, then validate and recoup mistaken underpayments made by CMS.


Pareto’s Premium Integrity analytics predict inaccuracies in member statuses that result in underpaid capitation payments. For this client, Pareto evaluated Medicare Secondary Payer and End Stage Renal Disease (ESRD) classifications to identify inconsistencies and prioritize reconciliation efforts. Pareto’s skilled outreach experts also coordinated confirmation of statuses and updates in the required systems.


Pareto’s Premium Integrity solution ingested and analyzed billions of data records and generated insights into attainable financial improvement for the client, which would be achieved by remediating payments with CMS.

1.4 billion

Processed and analyzed records of member, claims and government files

8 days

Processing time to turn raw data into actions

$11.5 million

In attainable financial improvement uncovered, with $8M attributed to mistaken ESRD determination


Per member financial improvement (based on average annual membership over a 6-year period)

Underpinning this project’s success is Pareto’s commitment to speed to value. We focus on providing actionable insights faster and more efficiently, so clients gain meaningful financial improvement that impacts in-year performance long-term revenue. In this case, the client was able to take action in just over 1 week from the completed data request.

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