Serving Beneficiaries

The MedExpert Solution

MedExpert’s strong experience in assisting clients with their Medicare populations—especially those in underserved and low-income areas—has shown considerable success in preventing disease and promoting wellness with an advanced outreach system of proven effectiveness. The success of this model, recognized in 2012 by the Centers for Medicare and Medicaid Services (CMS) through selection from more than 3,000 applicants with a prestigious Innovations Award, provides a firm foundation for analysis, outreach, medical education, chronic disease management, coaching, and behavior programs.

According to validated results with Medicare recipients, MedExpert is the only organization in the United States able to deliver a cost-effective, triple-aim solution to an entire population:

  1. Improve medical outcomes;
  2. Improve the health status of an entire population, and;
  3. Reduce costs for the total population.

MedExpert lets beneficiaries base today’s health care decisions on today’s information and protects the integrity of the Medicare system by electronically delivering EOMB to Medicare beneficiaries; identifying overutilization; identifying erroneous billings; identifying provider practice patterns; and identifying provider billing patterns. Independent and unconflicted, MedExpert puts the beneficiary and the payer first, reducing costs by up to an astounding 20%.

For our Medicare suite, products are broken into three categories:

Direct Decision Support (DDS)

Medical Management

Case Management


Member Navigation

Member Advocacy

Medicare 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 beneficiaries and helping them navigate the complex healthcare ecosystem.

On-staff doctors and nurses communicate the latest findings and health care intelligence in language your beneficiaries can understand and act on — often from the comfort of their own homes. Beneficiaries avoid unnecessary and duplicative tests and procedures when MedExpert is there to guide them to the most effective care paths in coordination with beneficiaries’ primary physicians. 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 beneficiary by infusing any medical decision—from losing weight to radical surgery—with the most current, accurate, and unbiased quality information available today. This is made possible because of the speed and power of AI, without which such a distillation of medical knowledge would take days, weeks, or more. Instead, MedExpert surfaces actionable information within minutes. Key to this process is the fact that the technology itself is essentially invisible to patients: the platform is utilized by MedExpert’s on-staff doctors and nurses, who then present this fully customized medical state of the art to beneficiaries using their preferred language, unburdened by medical jargon. With MedExpert, your beneficiaries now have the power of access to the world’s leading practitioners and researchers.

In legacy models, DDS is split among uncoordinated efforts at disease management, care coordination, case management, transition care, lifestyle management, patient advocacy, and patient navigation. MedExpert’s DDS not only fuses these elements, it accelerates them to align with the pace of human decision-making. And, critically, MedExpert makes this new generation of comprehensive DDS services cost-effective. A traditional suite of fragmented tools costs anywhere from $28 to $230 per person per month. With the power of our AI-assisted unified platform, MedExpert can provide deeper, more powerful DDS for $5 to $8 per person per month. The gains of a unified, automated platform are not additive, but exponential.


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.

Data & Oversight

Data from Everywhere

Data Today

MedExpert’s DAS provides administrators 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, managed care organizations, children’s health insurance, prescription drug plans, and dental insurers, among others.

This secure, on-demand data system provides Medicaid administrators 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.