Healthcare Payer Solutions

Healthcare Payer Solutions

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Transforming Payers Into Disrupters


Our Payer Consulting Services

Payers face a constantly changing environment fueled by consumers who demand high-quality care, an uncertain regulatory landscape, and competition from upstart, tech-first plans looking to corner segments of the market.

Health plans, Pharmacy Benefit Managers (PBMs), dental & vision plans, Accountable Care Organizations (ACOs), and First Tier, Downstream, and Related Entities (FDRs) want to do more than stay ahead of the curve. To do that, you need a partner than can help you anticipate, adapt and respond to changes and focus efforts and resources on risks and opportunities that can drive better business performance.

How We Can Help

Protiviti’s Payer professionals partner with you to understand the unique strengths, risks and opportunities of your organization and where you want to take your business. Whether we  assist with process improvements, strategic planning, Managed Care expansion, risk mitigation—or anything in between—we collaborate with you to apply innovation and  leading best practicesto enhance your business performance and drive sustainable growth.

Protiviti’s approach to payers is unique: our projects are staffed with tailored groups of multi-disciplinary professionals with deep payer experience, not just general healthcare knowledge, to provide you with the customized advice and recommendations you need to succeed. Our goal is to help you face the future with confidence. Please see below some of the various solutions we offer payers:


Member Experience

Members have more options than ever when selecting a health plan and they expect best-in-class experiences at every turn. Unlike other stakeholders in the healthcare ecosystem, payers have limited interactions with their customers, so they need to make all experiences positive and memorable. How we can help:

  • Digital Engagement Model
  • STARS scores
  • Improved quality
  • Health Outcomes Surveys
  • CX Platform Selection & Implementation
  • Member mailings
Vendor Oversight

Payers are delegating more functions to vendors than ever. Centers for Medicare and Medicaid Services (CMS), and other regulators, have taken notice and now want to see robust oversight programs in place to ensure vendors are compliant and are providing seamless experiences for members.

  • FDR Engagement Models
  • Procurement Efficiencies
  • Downstream Entities KPIs/KRIs
  • Vendor Attestations
  • Contract Management
  • Service Level Agreement (SLA) Enforcement
Actionable Analytics

Numbers on a spreadsheet no longer suffice for today’s payers. Your metrics must be real-time, provide insight into the data behind the numbers,and your organization’s leaders need to be able to act quickly based on the results. How we can help:

  • Root Cause Analysis
  • Dashboards/Scorecards using PowerBI and Tableau
  • PowerBI and Tableau
  • Use of Data in Leadership Decisions
  • Mitigating Security Risks
Smart Automation

There are limitless opportunities to automate processes within a payer’s operations. Automation can reduce errors by eliminating manual controls and can improve turn-around times, resulting in happier members and lower instances of noncompliance. How we can help:

  • Customized Workflows
  • Appeals & Grievances Processing
  • Claims Adjudication
  • Increased Productivity
  • Reduction of Manual Hours
Operational Improvements

As payers grown larger and acquire other organizations, org structures, engagement and operating models, and communication channels need to be optimized for efficiency and growth. Payers need to be agile while keeping administrative costs low. To achieve this, efficiency opportunities need to be uncovered and implemented throughout the organization. How we can help:

  • Org Structure Redesign
  • End-to-End Process Improvements
  • Operations Enhancement
  • Identifying Top Payer Talent
  • Employee Engagement
  • Scalable Agile Platforms
  • Shared Services Operating Models
Regulatory Compliance

Compliance can no longer be an after-thought. Payers must promote a culture of compliance throughout the organization so that compliance requirements are on the forefront of everyone’s thoughts, not just when a Program Audit is imminent. How we can help:

  • Compliance Program Effectiveness
  • Program Development
  • Stabilization and Corrective Action Plans
  • External Audit Preparation
  • Delegated and Downstream Oversight
  • Compliance Training Development
  • Medicare Chapters 21/9 Compliance
Payer Internal Audits

Audits can be leveraged more than ever as a strategic resource to provide guidance to payer leadership based on broad and deep skill sets and perspectives; analytical and digital capabilities; and internal knowledge of operations, strategic goals, and risk and control structures. How we can help:

  • Membership, Enrollment, Eligibility, and Reconciliations
  • Risk Adjustment Data
  • Provider Contracting and Credentialing
  • Appeals and Grievances
  • Fraud, Waste, and Abuse and Special Investigations
  • Annual Bid Process and Administrative Costs
  • Medical Loss Ratio Management
  • Claims Processing
Payer-Provider Relationships

Providers are extremely important to the healthcare ecosystem. It is important to keep providers happy as they will be interacting regularly with payer members—a member’s positive interaction with a provider can result in a positive perception of the payer. How we can help:

  • Provider Satisfaction and Engagement
  • Net Promoter Scores
  • Provider Contact Centers
  • Improved Prior-Auth Processes


What We’ve Been Up to Lately—A Sample of Engagements We Have Led in the Payer Space Recently:

Provider Directory Process Improvements – CMS has been laser-focused on provider directories over the last three to four years. It has been conducting more and more provider directory audits—and not only have the audits been bad (40%-60% incorrect information within the audit samples) the results even seem to be trending downward. There will be more audits and more penalties in the coming years, so we have been partnering with plans to implement process improvements to keep the directories up-to-date and correct.

Future State Engagement Models – Recently we led an engagement at a health plan to define an engagement model between its Medicare Operations Functional Areas and Shared Services to ensure operational efficiency. Deliverables included current and future-state process flow charts to visually showcase recommendations and opportunities for improvement, RACIs, and a future state roadmap.

Member Experience Analysis – We reviewed the Member Experience processes at a regional payer to data-mine appeals and grievances data so leadership could see the causes and trends related to member dissatisfaction. Our team built dashboards and implemented feedback loops into the sub-processes, and between business units, so issues could be acted on timely and consistently.

Data Integrity for Member Mailings – We assessed the controls and processes in place for ensuring the integrity and proper processing of member data by the Analytics Department and operational business units to provide to the Mail Room for mailing to plan members. A review was performed of the operational controls and coordination of information to identify and mitigate risks for information breakdown and the distribution of erroneous member information to the mail room prior to being mailed to members.


Schedule an Assessment


Ready to work with us?

Beau Fidler
Managing Director