Health plans and providers
Avalere Health’s dedicated Health Plans and Providers team supports commercial and government health insurance programs, providers, and benefit vendors.
Why choose us?
Informed by experience, backed by data
Our team combines first-hand, senior-level industry experience in strategic consulting, government programs, and health plan and payer organizations with unmatched data and analytics capabilities.
We provide actionable insights by leveraging extensive real-world data assets:
- 100% Medicare Part A/B/C/D data available through an agreement with the Centers for Medicare & Medicaid Services where Avalere accesses the Chronic Condition Warehouse Virtual Research Data Center.
- Longitudinal closed claims data through an agreement with HealthVerity — including a seamless ability to combine with other data types including EHR, SDOH, lab results, and mortality data
- Planscape,® comprehensive formulary and benefit design data, including cross-benefit coverage, formulary placement, coverage gaps, and utilization management
What we offer
We support clients navigating complex regulatory environments by delivering data-driven analyses to help client improve public policy and patient care.
We bring decades of Medicare Advantage, Medicaid, Exchange, and Commercial market expertise to:
Policy and policy analytics
Assess the impact of current events, legislation, and regulatory trends as you develop strategies to support vulnerable populations and efficient payment
Analytics and benchmarking
Advise on risk adjustment processes, coding, and analytics to support compliance; Validate risk scores to ensure accurate forecasting for bid submission and payment planning
Quality
Evaluate initiatives against best practices, forecast quality measure performance, and design initiatives that improve member outcomes and plan performance
Compliance
Evaluate, develop, and implement robust compliance programs and identifying areas of potential exposure and root causes of concern
Strategy and growth
Design end-to-end strategy that guides near and long-term decision-making for all aspects of payers' coverage and market activities
Operations
Design or enhance internal technical guidance, policies, and procedures for all operational activities with heavy focus on areas such as:
- Risk adjustment: Benchmark outcomes or cost to enhance provider performance and design benefits; Conduct economic studies to evaluate the performance of interventions, providers, or initiatives
- RFP and value proposition support: Create expansion, sales, marketing, and growth strategies; Provide hands-on support to winning value propositions and proposals
Our approach
Insight from every angle
Our Health Plans and Providers team brings deep subject matter expertise across the entire health plan landscape, delivering full-spectrum advisory support that evaluates strategy, risk, quality, and operations from every angle.
Backed by a global team of more than 1,200 Advisory, Medical, and Marketing experts, we unite strategy and insight, translating complex data into solutions grounded in real patient experience. We believe that meaningful change in healthcare starts with understanding the science, society, and systems that shape it, an approach called Sense Making. We apply that framework to every engagement.
We know that changing healthcare requires seeing it from every point of view, so we dig into its most complex layers and work side by side with clients to build practical, lasting solutions-always driven by robust data and focused on results that matter.
Who we help
Commercial plans
Affordable Care Act plans
Medicare Advantage plans
Benefits vendors
Providers
Medicaid Managed Care Organizations
Offerings
Policy tracking, analysis, and design
Program compliance
Business and market strategy
Payer/provider engagement
Operational improvement and redesign
Quality initiatives and reporting
Our work
How we have helped clients
Case study
Successfully expanding a health plan's access to Medicaid markets
We supported an established health plan in crafting a successful proposal response to retain access to three existing service areas and gain access to two additional Medicaid regions in a state with a large beneficiary population.
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Creating a strategic plan and implementation roadmap for a regional plan
A health plan serving Medicaid, Medicare Advantage, and D-SNP members in the northeast was refreshing its corporate strategy and sought Avalere’s support in analyzing and prioritizing market opportunities. Avalere Health helped the organization refine its strategy and develop implementation roadmaps to support their objectives of achieving growth and revenue goals. The client prioritized key states and markets of focus and identified the organizational initiatives needed to achieve its strategy.
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Assessing a Medicare Advantage plan’s Stars improvement operations to recommend best practices
A regional MA plan client, that also operated an MA plan under a subsidiary, wanted to ensure that its department focused on MA Stars Improvement was operating efficiently and effectively. The department worked cross-functionally across other departments as needed to influence Star ratings. Avalere Health evaluated quality indicators of the plan’s MA Stars operations and processes to identify gaps and recommend industry best practices to implement. Avalere Health identified priority initiatives and an implementation timeline to drive organizational investment in MA Stars Improvement. Avalere Health recommended key initiatives to implement industry best practices and close gaps.
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Our people
