Revenue and Payment Integrity

Revenue and Payment Integrity Success Story


A Blue plan serving approximately 1 million Commercial, Medicare Advantage (MA) and Affordable Care Act (ACA) members recognized the need for a comprehensive evaluation of revenue to ensure optimal outcomes and close any gaps impacting financial performance.


The health plan selected Pareto as a partner because of our unique and modern approach to capturing complete, accurate and compliant revenue. Rather than deploying point solutions to answer specific questions, Pareto evaluates all areas impacting revenue accuracy to isolate leakage and compliance concern, then works with client teams to remediate issues.

For this client, we applied intelligent analytics using our Revenue & Payment Integrity solution to uncover the drivers of financial performance and areas for improvement. Specifically, we evaluated:

Risk documentation completeness and accuracy to impact risk scores

Encounter data integrity across the ACA and MA markets

Capitated MA premium accuracy across Medicare Second Payer (MSP) and End Stage Renal Disease (ESRD) determinations

Claims payment accuracy through effective coordination with Medicare benefits (COB)


Our evaluation identified multiple improvement opportunities for this health plan, resulting in over $10 million in financial impact over the last 2 years, as well as a substantial risk score increase for both the MA and ACA markets.


risk score increase for each market (i.e., MA and ACA)

$3.7 million

($20 PMPY) in EDGE errors identified for the ACA market

$1 million

($30 PMPY) in RAPS and
EDS gaps identified for the MA market

$2 million

($67 PMPY) in recoveries for resolved MSP entitlement determinations

$4 million

recovered through improved COB efforts


($30K per ESRD identified
member) in recoveries identified for misclassified members

Contact us to learn more about our Revenue & Payment Integrity Solutions.

See it and Believe it

Our demos say it all. Tell us about your challenges and we’ll show you how we can help you overcome them.

Schedule a Demo