Serving Employers and Employees

The MedExpert Solution

MedExpert is proud to have served commercial health plans since the early 2000s. MedExpert provides the world’s only second-generation total population health solution for groups who need to significantly lower the cost of providing first-rate health care while engaging their employees with the best in wellness and incentive programs, including: coaching, biometrics, plan design, reporting, and communication.

In addition, MedExpert protects the integrity of purchaser payments by: electronically delivering EOMB to employees; identifying overutilization; identifying erroneous billings; identifying provider practice patterns; and identifying provider billing patterns.

With MedExpert, no employees will be excluded from our services because our programs are uniquely capable of working for any member, regardless of medical condition.

For our Commercial suite, products are broken into five categories:

Direct Decision Support (DDS)

Medical Management

Case Management


Member Navigation

Member Advocacy

Medical management is best served by a fully integrated, fully automated, suite of tools under one roof that assists employees with any medical concern—as opposed to the fragmented tools that address small parts of populations that has become the low-bar standard of today.

Employee populations grow healthier and less resource-intensive through a DDS component that easily keeps pace with today’s frenetic pace of innovation while advocating for patients and helping them navigate the complex healthcare ecosystem. Emergency room use and unnecessary surgeries are reduced significantly when MedExpert becomes part of your population’s health ecosystem. MedExpert’s DDS works at the level of the patient by infusing any medical decision—from losing weight to radical surgery—with the most current, accurate, and unbiased quality information available today.

Our DDS encompasses case management; disease management that extends to all 22,000+ medical conditions and comorbidities; care coordination among attending and consulting physicians; and health care system navigation and patient advocacy.


Lifestyle Management

Wellness Outreach

Member Portal

Wellness – the concept of approaching health care from the perspective of preventive, anticipatory care – has been largely lost in the understandable push to find manageable, and reconcilable, pieces of a financial and marketing juggernaut. But beyond the flush of early excitement, true costing and reporting rooted in reality require more than lovely phrasing. MedExpert was designed from its core to forego pleasantries and instead to focus on how to address population health in a way accountable to employees.

MedExpert will “touch” 85%-90% of all employees, and MedExpert will have meaningful health and wellness discussions with 45%-55% of all employees. MedExpert achieves this through our unparalleled outreach capabilities, along with decades of experience in engaging members. If given full claims data, MedExpert can target and outreach to members on any given factor. 

MedExpert provides each employee/spouse with a HIPAA/HITECH secure portal that provides each member with their specific program details, including medical results, assessment results, biometric results, medical incentives, location finders for services, and personal evidence-based medicine reports. The portal works seamlessly across smartphones, tablets, computers, and iPads.


Maximum Benefit

No Disruption

ReconHealth is an innovative, game changing, member centric, and powerful integrity program providing insight, transparency, and accountability into your health care landscape. ReconHealth protects both patients and payers.

Integrity is an industry term that encompasses protection from fraud, waste and abuse. Fraud involves intentional deception and scheming to obtain money or property that belongs to the health care system. Waste is the overutilization of services and practices, directly or indirectly resulting in unnecessary costs to the health care system. Abuse involves unsubstantiated payment for items or services, often when the provider is unaware that such payment has been requested.

ReconHealth addresses all these components of integrity by combating fraud, stopping waste and identifying abuse.

Why we need ReconHealth
There is an enormous need to address the fraud, waste and abuse in health care. Last year, the U.S. spent more than $3.65 trillion on health care. Conservative estimates of health care fraud alone range from 3% to 10% (up to $365 billion) of total national spend. Additionally, combined “waste and abuse” account for 30% of the $3.65 trillion. At stake is at least $1.2 trillion lost annually to fraud, waste and abuse. And spending is growing. National health expenditures are projected to grow at an annual rate of 5.5% through 2027.

How does ReconHealth work
ReconHealth closes the loop on patient involvement in care with two key elements:

  1.  MedExpert’s ReconHealth includes a patent pending method to engage members before and after their provider visits to confirm what aspects of care did or did not occur. In short, following an appointment or service, a member is afforded the opportunity to review, in a simple manner, precisely what was paid for on their behalf. Finally, a new technology: an integrity system that rewards and captivates members to participate in the integrity of their own care.

    2. MedExpert’s integrity system motivates members and improves their health care knowledge with access to real-time evidence-based medicine (EBM). This creates smarter and healthier members and is a proven decision support process to address waste by reducing spending on unnecessary services, procedures, equipment and pharmaceuticals.

Medical Utilization

Utilization Management

Network Verification

True Informed Consent

MedExpert provides our commercial clients with Informed 2.0, a second-generation utilization management tool that infuses expert opinion and the latest medical research into critical patient care decisions. Informed 2.0 allows employees to understand all the advantages and disadvantages of particular treatment options and to establish the standard of care.

For many employees/spouses in a health plan, simply determining whether a particular provider is in network or not can be a confusing process. Because so much money is at stake with getting this information right, MedExpert includes its service of answering this question.

With MedExpert’s unique Informed 2.0, your employees are given full transparency into the pros and cons for any procedure or treatment as it pertains to them as individuals. For many employees/spouses in a health plan, simply determining whether a particular provider is in network or not can be a confusing process. Because so much money is at stake with getting this information right, MedExpert includes its service of answering this question, and patients find the most optimal treatment path possible.

Data & Oversight

Data from Everywhere

Data Today

MedExpert’s DAS provides HR with a data analytic system that allows for near-instantaneous insight into cost containment and quality improvement efforts. MedExpert extracts, translates, loads, verifies, authenticates, and maintains all medical, pharmaceutical, dental, vision, claim, and encounter data from all data sources servicing the population. Eligibility data is coupled with payer data from Medicaid/Medicare, managed care organizations, children’s health insurance, prescription drug plans, and dental insurers, among others.

This secure, on-demand data system provides HR with powerful analytics on current data, right away. Indeed, MedExpert is distinguished by integrating and normalizing data within 24 to 72 hours of receipt. This means you can query the system for activities that occurred last week. You no longer need to wait weeks and, in some cases, months to learn from your own data.