We enable Medicare Advantage, PACE plans, and risk-bearing providers to recover underpaid member premiums through comprehensive reconciliation of MSP and ESRD status. This supports revenue accuracy for active and terminated members.
Our premium integrity solution is designed for cross-functional health plan and risk-bearing provider group leaders who manage compliance, revenue, and enrollment operations.
Ensure CMS has accurate information to successfully manage order of payment
Recover missed revenue and reconcile revenue to cost of members across all lookback period years
Maintain accurate order of liability information to ensure accurate claims payment
Too many plans treat premium reconciliation as a one-time audit. Pareto offers a smarter way. Our compliance-first solution combines predictive analytics, outreach, and resolution tracking to ensure premium accuracy year-round, while delivering financial transparency and comprehensive documentation in event of CMS record request.
Proprietary analytics uncover premium underpayments caused by status misclassifications across MSP and ESRD—so premiums reflect the actual cost of care for these members
We correct Medicare Secondary order of liability reporting issues and ensure CMS alignment through traceable documentation within ECRS, and auditable notes
Actionable insights are delivered in days, not months, via a platform built for speed, accuracy, and an unmatched success percentage while keeping compliance in mind
Premium Integrity doesn’t just find short-term discrepancies, it drives long-term resolution through outreach, system updates, and ongoing monitoring
It resolves MSP and ESRD special enrollment status errors to correct underpaid premiums, while maintaining documentation for potential CMS audits.
Clients using RevenueIQ often recover $30–$250 per member depending on the issue, with total gains ranging from thousands to millions.
Pareto supports premium analytics for the full allowable look-back period according to CMS regulations.
Most plans receive actionable insights from RevenueIQ within 10–20 days of data intake, with recoveries often following within the same quarter.
Yes. PaymentIntegrityIQ focuses on provider payments and claims payment accuracy; RevenueIQ for Premium Integrity addresses monthly member premium accuracy realized from CMS.
We use predictive analytics, outreach, and system updates to resolve MSP and ESRD issues that impact revenue.
Proprietary algorithms predict eligibility status with 95% accuracy using clinical and non-clinical data.
Our outreach specialists confirm member statuses and adjust information for clients to ensure accuracy with CMS.
We update ECRS, submit ESRD tickets, fix data mismatches, and support enrollment.
A dashboard and monthly recoveries prevent future premium revenue leakage and ensure alignment with CMS information.
On June 28th, 2019, the Centers for Medicare and Medicaid Services (“CMS”) released the Affordable Care Act (“ACA”) Risk Adjustment Transfer Payment results for the 2018 benefit year. Within days
A condition that if present generates a special status flag within the Monthly Membership Report (MMR) and changes members’ monthly premium payments; proper status is critical for accurate premium reimbursement, as variance results in upwards of $5,000 a month.
A special enrollment eligibility flag that designates if the MAO or a Commercial plan is responsible for primary payment for a member’s care. Proper designation is critical; variance may result in a premium difference of $200 - $300 per member per month.
Fixed monthly payments CMS makes to Medicare Advantage plans based on member risk scores and eligibility classification.
Mandatory CMS reporting for group health plan to determine correct MSP status; errors can lead to improper order of claims payments and monthly premiums for MA health plans.
Pareto Intelligence is a healthcare analytics and technology company that helps health plans in government-sponsored markets improve financial performance and regulatory compliance. Our platform delivers actionable insights across premium reconciliation, risk adjustment, Stars, and member engagement—so plans can recover revenue, close gaps, and stay CMS-ready.
With solutions like Pareto RevenueIQ for Premium Integrity, Pareto enables Medicare Advantage and Medicaid plans to identify capitation errors, correct member eligibility status, and recover millions in missed payments. Backed by a team of experts and trusted by 75% of the nation’s largest health insurers, Pareto combines analytics, advisory, and automation in one integrated platform.
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