FOR HEALTH PLANS, RISK-BEARING MEDICAL GROUPS, IPAS AND MSOS
Find the margin your managed care business is losing.
A health plan CFO and a quality executive with 50+ years combined in managed care. We find where health plans and capitated groups lose money and help fix it, using the data you already have.
WHY NOW
Costs keep rising
Plans and groups need 1.5–3% better margin a year just to keep pace.
Quality money is moving
2027 Star Ratings drop and add measures; incentives shift with them.
Risk scores reset
V28 lowered many groups’ scores, and revenue with them.
WHERE WE LOOK
We don’t rush to answers.
We start with questions, test our hunches with you, and let your data take us from there, across six domains.
Risk adjustment
Chronic conditions don’t carry over on their own. Every year, each one needs a visit and documentation coded to its full, accurate complexity, or the revenue that pays for that member’s care disappears. Are your members being seen, and is the record capturing how sick they really are, now that V28 has reset the scores?
Quality and Stars
Which incentive dollars are you leaving on the table, and why do the gaps stay open? At the 4-Star line, a single measure can decide the bonus. We look for gaps that were closed but never captured, missing supplemental data, and the triple-weighted medication adherence measures, as 2027 drops some measures and adds others.
Utilization and care transitions
Where do avoidable admissions, ED visits and readmissions start, and who owns stopping them? Observation versus inpatient admission matters, since a short stay billed as an admission costs a full DRG. We also look at bed days and delayed discharges, skilled nursing stays that run long, care that could move to a lower-cost setting, and follow-up within seven days of discharge.
Contract value
Two sides of every contract. Upstream: are you earning everything your payer contracts allow, from quality and incentive dollars to blended rates where your actual care, like your C-section rate, beats the assumption? Downstream: are you getting what you pay for from your own providers, or is care leaking outside capitated arrangements and costing you fee-for-service on top? And is every dollar you pay actually yours to pay? Some care belongs to another program, and some falls outside what your contract makes you responsible for.
Payment integrity
Are you paying claims you shouldn’t, or paying more than the care supports? Recovering overpayments helps, but it’s the costly way: you never get it all back, and recovery vendors take a share. The better goal is catching errors before payment. We assess your claims logic, coding edits and recovery approach, size what’s slipping through, and connect you with specialized partners for the work itself.
Pharmacy
Which drugs and adherence gaps are driving cost and costing you Stars? We look at specialty and high-cost drugs, including those billed under the medical benefit that often go unmanaged, whether you’re sourcing them through the lowest-cost channels available to you, and the triple-weighted adherence measures. After a hospital stay, medication reconciliation often stops at checking the box. The value comes from closing the loop: the prescriber reviews the findings and clears the concern or changes the medication, and the member, and often their caregiver, understands what changed.
Where there is variation, there is opportunity.
At a New York senior care plan, authorized hours ran well above what members’ assessments supported (orange). Expected-hours ranges, medical director review and focused work lists closed the gap.
Profitability up $25M, with minimal disruption.
Illustrative data.
The deliverable isn’t a 60-page deck.
It’s a picture your team acts on.
HOW WE WORK
Alongside your clinical, operations and finance teams, using your existing data. No new systems.
We put AI to work so your team doesn’t have to. It helps us capture your goals and priorities, map how work actually flows, and work through the data you already have to find the variation: the providers, members and processes that land well outside what’s expected. That frees us to spend our time where 50+ years of combined managed care experience matters most: why the variation is there, what it’s worth, and what your team can actually do about it.
1
ROOT CAUSES
Find what’s really driving the gap
AI surfaces the variation; we follow it to the few causes that matter.
2
THE RIGHT LEVER
Most result, minimal disruption
A dollar value and an owner on every finding.
3
MEASURE AND FOLLOW
Keep the gains
Simple metrics, tracked until the result sticks.
WHAT IT’S WORTH
Small improvements. Large dollars.
Health plans and risk-bearing groups typically aim to improve 1.5% to 3% a year just to stay ahead of rising costs. Measured against the revenue a group manages, that is millions of dollars. Our work needs only a small part of it to pay for itself many times over.
AN ILLUSTRATIVE GROUP: 150,000 MEMBERS
$660M
revenue managed each year
$8.6M
value of a 1.5% improvement in Medicare and Medi-Cal
<0.5%
covers a $100K engagement ten times over
Illustrative only, based on a typical mix of Medicare Advantage, Medi-Cal and commercial members; improvement is measured on Medicare and Medi-Cal, where most margin gains come from. Actual results depend on your contracts, membership and data.
Then we help you keep it
Gains fade without someone owning them. After a diagnostic, our fractional quality and analytics leaders can stay on to lead the work, so you hold on to the results without a full-time hire.
See your own numbers in a 20-minute review.
DIAGNOSTICS
Two fixed-fee diagnostics
Focused
Fixed fee
One line of business, usually Medicare Advantage
Risk adjustment, HEDIS/Stars, and inpatient utilization and care transitions. Top 3–5 opportunities sized in dollars, with a 90-day action plan. Readout 4–6 weeks after complete, usable data.
Full
Fixed fee
Your chosen lines of business
The Focused areas across your lines of business, plus Medi-Cal risk adjustment, medication and care management, provider engagement, contracts and risk pools, and payment integrity review. Top 5–8 opportunities with a roadmap.
FRACTIONAL EXECUTIVES
Senior leadership before you need a full-time executive
A diagnostic shows where the money is. Someone still has to own getting it. Our fractional Chief Quality Officer and Chief Analytics Officer lead your team, usually about a day a week, set the priorities and the cadence, and leave the function stronger than they found it.
Fractional Chief Quality Officer
Owns quality performance and the incentive dollars that follow it
- Stars and HEDIS strategy, measure by measure
- Quality incentive revenue and supplemental data
- Medication adherence and member experience
- Quality committee, provider accountability and corrective action plans
- Executive and board reporting
Fractional Chief Analytics Officer
Gives management answers to the questions that drive margin
- Analytics strategy, priorities and the KPIs that matter
- Medical cost, utilization and risk adjustment analytics
- Provider, contract and pharmacy scorecards
- Data quality and vendor oversight
- Executive dashboards and responsible use of AI
WHEN IT FITS
Too early for full-time
You need the capability before you need the headcount.
A gap at the top
You have strong managers and analysts, but no one at the executive level connecting the work.
Interim leadership
A leader has left, a merger or new contract is underway, and results can’t wait for a search.
HOW IT WORKS
A monthly retainer, usually about a day a week: executive guidance, a regular leadership cadence with your team, and reporting to your executives and board. When the work calls for more, including interim leadership while you recruit, we’ll scope it with you. Major data builds and chart work are a separate project. Success means you outgrow us and hire the permanent leader.
Build the function. Lead it. Leave it stronger.
Talk with us about the right level for you.
RESULTS
Results from our prior roles
$22.8M
Est. annual savings on 130,000 capitated Medicare lives at a large Southern California risk-bearing network
$25M
Profitability gain, market-leading Senior Care Plan in New York
77% → 94%
HEDIS measures above state targets in two years, Anthem Blue Cross California
0.98 → 1.2
Risk adjustment score, Molina Healthcare of California
CASE STUDIES
How the results happened
NEW YORK SENIOR CARE PLAN
Profitability up $25M
A market-leading senior care plan in New York was losing money on personal care. Howard led the analysis and the project. The data showed hours authorized above what members’ assessments supported, and providers requesting extra hours; when those were denied, members moved to other plans. It also showed heavy use of full-day care, and members receiving both personal care and adult day care. The team built expected-hours ranges tied to assessed need, added medical director review for requests outside those ranges, and gave staff focused work lists. Progress was reported every two weeks and monthly to the plan president, CMO, CFO and CNO. Profitability rose $25M, with minimal disruption.
ANTHEM BLUE CROSS CALIFORNIA
77% to 94% of quality measures above target
As Regional VP of Clinical Quality Management, Joy took Anthem Blue Cross California from 77% to 94% of HEDIS measures above state targets in two years. The work combined a direct provider incentive program with performance improvement projects for dual-eligible (D-SNP), long-term services and supports, and Medicaid members. NCQA scores rose 1.5 points and member satisfaction (CAHPS) rose 8%.
MAGELLAN COMPLETE CARE
$9.5M in performance dollars
At Magellan Complete Care, Joy led quality across six markets. In Virginia, damages fell 78%, securing $9.5M in performance dollars. In Florida, HEDIS results for members with serious mental illness rose 70%. Nationally, the Medicare team reached 4 Stars, and 80% of measures improved 5–20% in two years.
ANTHEM BLUE CROSS CALIFORNIA
$20M in overpayments found and fixed
A claims configuration analyst at Anthem’s California Medicaid plan noticed a setup error. On office-administered injectable drugs, the administration fee was being paid on every unit of the drug, not just once per injection. No one had sized it, fixed it or planned how to recover the money. Howard took it from there and managed it start to finish. He sized the overpayment at $20M and worked with configuration staff on the operational fix. He then led recovery of past overpayments, going back as far as California regulation allows, and planned how providers would be told. With the fix in place, future overpayments stopped, and Howard measured claims payment accuracy to confirm the correction held.
Who we are
Howard Abugow
Partner, finance and analytics
Former CFO and Assistant CFO of Medicaid health plans at Anthem, Molina and CVS/Aetna, with 25+ years in healthcare finance, analytics and medical economics.
Joy Bland, DBH, RN, CPHQ, CCM
Partner, quality and clinical operations
25+ years leading quality and clinical operations across Medicare, Medicaid and commercial programs at Aetna, Magellan, Anthem and Molina.
Why “Integrum”: from the Latin restitutio in integrum, “restoration to the whole.” We find what is already yours and help you bring it back.
Let’s find your margin.
A 20-minute call: we walk through your public quality and financial data and name the two or three places money is most likely leaking.
info@integrumhealth.ai
(805) 217-9270
integrumhealth.ai
LinkedIn
Southern California