Managed Care Organizations

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As managed care organizations (MCOs) navigate regulatory shifts and drive change across programs, their priorities are spread across the healthcare landscape. From improving efficiencies to elevating experiences to forecasting future risk, they face many challenges. With decades of experience helping MCOs simplify the complex, Gainwell has proven solutions and experts you can trust to streamline processes and gain value.

We are passionate about empowering MCOs to achieve better care coordination that ultimately yields better health outcomes.

Modernization Support Across the Care Continuum

Improving care standards

Balancing costs

Identifying risks

How We Can Help

Our services and solutions are purpose-built to intelligently mitigate risk, streamline the most complex processes and improve the overall quality of care delivered.

Our Coordination of Benefits solutions are innovative, creating unmatched cost and claim clarity, while our Payment Integrity tools root out claims that are erroneous for any reason, at any stage in the claim cycle. All of these solutions are bolstered by AI and machine learning to keep you on the leading edge, always a step ahead.

Coordination of Benefits

Pre-payment Solutions

Our goal is always to maximize cost avoidance for your plan. Our tenured market expertise pairs with end-to-end COB solutions to amplify speed to delivery and provide truly actionable insights.

Post-payment Recovery

Our Post-Payment solutions leverage AI and machine learning to examine improperly paid claims. Then, we pursue those recoveries using proven, efficient digital processes to maximize savings.

Case Management

Our Case Management solution makes sense of complex data and drives cases to reimbursement and closure. We deliver secure, reliable, web-based access around the clock — with real-time updates, document imaging and a guided workflow. Our case managers and attorneys are unmatched when it comes to complex, high-dollar cases.

Payment Integrity

Clinical Claim Reviews

Our Clinical Claim Reviews identify coding, location, level of service and reimbursement errors by comparing claims against medical records — either pre- or post-pay.

Eligibility Verification

Our Eligibility Verification solution not only effectively handles verification, but also prioritizes employee clarity — ensuring they know why someone is ineligible.

FraudCapture®

FraudCapture is a modular, cloud-hosted platform that provides end-to-end support in the identification of fraud, waste and abuse, exposing issues through clear visualization and easy-to-navigate exploration tools.

Payment Analytics

Customize your post-payment solution to meet your specific needs. We use proprietary data analysis tools to compare claims history across many criteria that client systems or claim processors often miss.

Care Management

Our interoperable Care Management platform is built on a foundation of automation, standardization and mature processes, utilizing data from proven, industry-standard COTS products.

Utilization Management

Utilization Management addresses your most pressing needs by combining cost management with accurate pre- and post-payment claim reviews and prior authorization from our Clinical Care Reviews.

We can help. But the next move is yours!

Please fill out the information below to start a no-pressure chat with one of our knowledgeable solutions experts.

Additional Insights

TRICARE and Medicaid Coordination of Benefits: The System is Broken
Generate Pre-Payment Claim Review Savings by Aligning Payer & Provider Incentives
How Pre-Payment Integrity Can Incentivize Evidence-Based Care
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