As healthcare continues its shift toward value-based care (VBC), health plans face increasing pressure to support more sophisticated payment models while managing operational complexity. Many organizations struggle to scale programs efficiently due to fragmented data, manual processes, and disconnected systems. Building a scalable foundation has become critical to accelerating VBC adoption and supporting long-term growth.

For one national member-owned health plan serving more than 20 million members across the United States, these challenges became increasingly apparent as its value-based care strategy expanded, including care programs, Medicare products, prescription drug coverage, dental and vision benefits, and indemnity insurance.

As the healthcare industry continues its transition toward value-based care, the organization recognized an opportunity to expand and mature its value-based payment programs while creating greater operational efficiency and alignment across the enterprise. To achieve these goals, the plan sought a more scalable approach to designing, administering, and growing increasingly complex value-based arrangements.

The challenge: Homegrown solutions and slow adoption

The health plan had established accountable care organization (ACO), capitation, and episodes of care (EoC) programs using internally developed solutions. While effective in supporting initial efforts, these homegrown systems required significant manual effort and technical resources to maintain and enhance.

As a result, launching new programs was often time-intensive, limiting the organization's ability to scale. At the outset of its relationship with Cotiviti, the plan managed fewer than 30 value-based contracts and was introducing only a small number of new programs each year.

Leadership identified several priorities:

  • Reduce dependence on custom-built solutions
  • Create a unified foundation for value-based payment administration
  • Improve collaboration across business units
  • Accelerate adoption of more advanced alternative payment models
  • Establish the operational flexibility needed to support future growth

Finding a solution to support the full value-based care lifecycle

The health plan was seeking more than a point solution. While many vendors offered capabilities focused on analytics or modeling, the organization needed an integrated approach that could support program design, implementation, administration, monitoring, and settlement activities from a single platform.

With Value-Based Contracting and Payment Administration , the plan gained the ability to manage value-based payment programs across multiple models while creating a more consistent operational framework for execution and growth.

As the organization expanded across a range of value-based payment models, it needed a solution capable of supporting accountable care, capitation, and episodes of care programs. VBC Payment Administration enabled the plan to consolidate program administration and create a more consistent operating model.

By bringing together data from disparate sources, VBC Payment Administration helped establish a more connected foundation for value-based payment administration. The solution's approach to data accessibility also enabled information to flow more efficiently to downstream financial and operational systems, reducing complexity and supporting greater organizational visibility.

A collaborative implementation

Working collaboratively with stakeholders from actuarial, operations, strategy, and platform teams, the implementation program established a shared framework for managing value-based payment initiatives across the enterprise. Within eight months, the organization was prepared for testing and positioned to begin scaling its value-based care operations.

During implementation, key member, provider, claims, quality, and risk data sources were integrated into a unified foundation capable of supporting a broad range of LAN payment models. The project team also reviewed existing business requirements and translated them into reusable program templates.

By introducing a more standardized approach to implementation, the organization significantly reduced the effort required to onboard new contracts and payment arrangements.

This repeatable framework provided the flexibility needed to expand value-based programs more quickly while supporting continued innovation in reimbursement design.

Results

The organization established a scalable operational model for administering value-based payment programs across multiple reimbursement structures. With a stronger data foundation, standardized contract configuration, and streamlined implementation processes, the plan significantly accelerated the growth of its value-based portfolio.

Following deployment of VBC Payment Administration, the organization:

  • Expanded value-based contracts from fewer than 30 to more than 3,000
  • Achieved more than 100x growth in value-based contracts
  • Created a repeatable framework for implementing and scaling new payment model
  • Established a unified data foundation supporting all LAN value-based payment models
  • Streamlined the onboarding of new capitation arrangements
  • Supported retrospective processing of eligibility and enrollment changes
  • Reduced administrative burden while improving operational efficiency, realizing 5x operational cost savings