Population Health &
Cost Management Solutions

An integral part of HORIZON Health Ventures, LLC's suite of solutions includes the delivery of population health management and cost containment services. In concert with our premier service partners, it is HORIZON's goal to positively impact quality, cost and outcomes in healthcare.

HORIZON maintains its leadership in care and cost management by delivering strategies, tools and technologies designed to identify opportunities for improving the quality of care, identifying and addressing inaccurate or inappropriate care and cost thereby lowering plan costs and improving outcomes.

Our portfolio integrates medical management solutions across the healthcare continuum, medical bill review, Reference Based Reimbursement, clinical auditing, provider negotiations, prospective, concurrent and retrospective utilization management, case management and disease management programs. Each of these programs is led by nurses, physicians and supported by negotiation experts.

All of HORIZON's Population Health Management solutions are enabled by the architecture of the StrateBen Platform, which is a fully integrated next generation technology platform, built on an infinitely scalable and configurable business rules engine, referencing national and regional coding standards, with care interventions guided by predictive analytics and evidence-based medicine. This platform was built to address transparency and eliminate the fragmentation in cost and care management solutions, consolidate the services of our strategic partners, and capitalize on the synergistic impact of integrating the clinical and financial components of medical management.

Medical Bill Review (MBR)

Our Medical Bill Review (MBR) is an industry changing solution, allowing employers to significantly reduce expenses for hospital and facility claims. MBR provides a transparent, equitable alternative to today’s ever-rising and traditionally unchallenged hospital and facility bill mark-ups.

Bitter Pill Slide

At the foundation of the MBR program is Advanced Medical Pricing Solutions (AMPS) proprietary “Dragon” claims processing engine. Well over ninety percent of medical bills contain errors, and due to inefficiencies within the healthcare system, these errors go largely undetected. Current methodologies lack the robust technology, physician review and analytics, which result in inflated costs that steal directly from your bottom line. The AMPS technology driven, physician led bill review will insure that only valid claims are paid, and fabricated claims are exposed.

Our clients access these powerful processing capabilities, advanced data security, a team of industry leading doctors and medical professionals, a call center equipped with clinical specialists and the leading ERISA legal minds resulting in a significant reduction in our clients health plan costs.

Reference Based Reimbursement (RBR)

As an alternative to MBR, AMPS also delivers an industry changing solution, Reference Based Reimbursement (RBR). RBR provides an equitable alternative to today’s ever rising and traditionally unchallenged hospital bill mark-ups. Using multiple data points including Medicare rates, cost-to-charge ratios, and over nine years of historical data as its baseline, RBR ensures fair reimbursement for member, plan and provider.



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Success Stories
Association Employer – New Jersey – HORIZON Solution: Employer Group Waiver Plan (EGWP)

Number of Retirees: 239
This Association had been managing their retiree pharmacy program and filing for the Retiree Drug Subsidy (RDS) since 2006 through its insurance carrier. After evaluation of current drug spend and projected RDS for 2014, the plan decided to move to a fully insured Employer Group Waiver Program (EGWP). Based on current enrollment, no change in plan design or drug plan, the group saved $430,000 or $1,800 PMPY. This was hard dollar savings and did not infer savings from the elimination of attestation, administration or from the elimination of OPEB liabilities.

Success Stories
Government Association - Washington, DC- HORIZON Solution: Employer Group Waiver Plan (EGWP)

Number of Retirees: 108
This Association had been managing their retiree pharmacy program and filing for the Retiree Drug Subsidy (RDS) since 2006 through its Pharmacy Benefit Manager (PBM). During the course of the relationship, the PBM never introduced the Employer Group Waiver Program (EGWP) to either the Association or their insurance broker. In May 2013, HORIZON Health Ventures introduced the concept of EGWP to the broker who immediately addressed the capability with the client. Keeping all pharmacy benefits the same, HHV was able to save this plan $189,000 or 28% of drug trend for 2014.

Success Stories
Municipal Employer –Michigan – HORIZON Solution: Employer Group Waiver Plan (EGWP)

Number of Retirees: 1,200
Managed for many years by the same carrier, this municipality moved their group retiree pharmacy program to HORIZON Health Ventures and its proposed Employer Group Waiver Program (EGWP) for a 13% savings to the plan. In addition, the group did so while improving their plan design on generic drugs. At the direction of HORIZON Health Ventures, the EGWP provider lowered copayments on generic products both at retail and mail thus resulting in greater steerage to lower cost products and thus a lower premium. In addition, based on this client’s plan year, (along with the new plan design adopted), the client was able to secure a rate cap for 2015 fixing their costs at a maximum liability until January 1, 2016.

Success Stories
Union – New Jersey – HORIZON Solution: RDS Reopening

Retirees Covered: 1,032
Reopening subsidy = $1,518,000
Additional subsidy = $280,000
18% additional subsidy recovered upon Reopening

Upon hiring HHV and RDS Reopening Services requested an audit of past Retiree Drug Subsidy filings from CMS. The request was approved and based on missed eligibility and inaccurate reconciliation of subsidy eligible claims, this client successfully Reopened their RDS filings from 2009-2012 recovering over $90,000 in additional subsidy. 

Success Stories
Municipality – New Jersey – HORIZON Solution: Pharmacy Benefit Management

Total Lives Covered – 2,900
Annual Drug Spend - $4,400,000
Issue – Adverse drug mix in the Proton Pump Inhibitor (PPI’s) category resulting in $297,000 in unnecessary drug spend.

Resolution – Plan design modification mandating PPI’s be purchased Over-the-Counter (OTC) along with full subsidy of a $0 copayment to the member.

Recommendation to eliminate member cost share for mandatory purchases of OTC PPI’s resulting in $177,000 net savings to the plan. Significant savings to both plan and member realized through slight modification of design and no member disruption.

Success Stories
Corporate Employer – Pennsylvania – HORIZON Solution: Medical Bill Review

Total Lives Covered – 400
Number of bills reviewed - 5
Total Amount of Hospital Bills Reviewed - $1,135,914
Negotiated Amount Paid by Plan Sponsor - $446,874

After hiring HHV for Cost Containment Services (Medical Bill Review), five out-of-network hospital bills (different patients with different health conditions) were reviewed for appropriateness and necessity. Due to the identification egregious billing practices, undocumented charges and reasonableness audit, successful negotiation was realized reducing the amount paid by $690,000.

"20-40% of ICD pacemakers are implanted contrary to clinical practice guidelines at $200,000 per patient.  Once implanted, they cannot be removed." 

National Cardiovascular Data Registry