QualChoice Health Insurance Chooses TriZetto’s Payment-Bundling Solution to Help Improve Cost and Quality of Care for Members

<0> Flexible Software Supports Multiple Models of Episode-Based Provider Payment </0>

QualChoice Health Insurance Chooses TriZetto’s Payment-Bundling Solution to Help Improve Cost and Quality of Care for Members

<0> Schwartz MSL BostonDavida Dinerman / Nicole Solera, 781-684-0770orThe TriZetto GroupLoren Finkelstein, 303-542-2460 </0>

., today announced that , Arkansas’ second-largest managed care company, is using TriZetto software to administer to physicians who provide cardiac stents, perinatal care and hip and knee replacements for its group and individual health plan members. Under the new payment model, physicians and facilities will share cost savings or incur performance penalties, based on how well they complete episodes of care at appropriate levels.

Little Rock-based QualChoice is partnering with Medicaid, other private payers and hundreds of physicians, healthcare professionals and other stakeholders to implement the Arkansas Health Care Payment Improvement Initiative, which began on July 1. Participants in the state-sponsored program use an to control costs and reward healthcare providers who deliver high-quality, coordinated, cost-effective care to patients.

“QualChoice chose TriZetto’s payment-bundling administration solution because it automates and streamlines retrospective prospective episodic-payment models,” explained Michael E. Stock, president and CEO of QualChoice. “Under the state program, physicians and facilities are rewarded retrospectively – months after the service – with shared savings for meeting quality and cost standards for select episodes of care. Beginning in 2013, however, QualChoice will have the ability to reward providers prospectively – with immediate cost savings – for meeting quality and cost targets. TriZetto’s highly flexible solution, which we implemented in just three months, will support retrospective and prospective payment models, allowing us to continually innovate to improve member health and best serve our employer customers.”

In recognition of QualChoice’s innovation and commitment to community and member health, the Arkansas Business Publishing Group this year recognized the company with its coveted Arkansas Business of the Year Award. This distinction came as no surprise to Jay Sultan, TriZetto’s general manager of payment reform.

“QualChoice continues to demonstrate tremendous foresight and leadership,” he said. “QualChoice knows the future of U.S. healthcare lies in value-based reimbursement, not in the current fee-for-service model driving unwarranted variations in care that compromise member health and increase costs. Our payment-bundling administration solution will support QualChoice as it collaborates with providers to improve the health of Arkansans.”

The prevailing fee-for-service model rewards providers based on the volume of care they deliver. Conversely, episode payment, a form of value-based reimbursement, incents providers to coordinate in delivering the most cost-effective, evidence-based medical services across episodes of care. For example, in a fee-for-service model, the many providers engaged in perinatal care function independently. A single, episode-payment approach encourages caregivers to function as one team, share information, coordinate treatment and provide patient-centered care throughout an entire pregnancy.

TriZetto’s patent-pending payment-bundling application automates and streamlines the processing of episode-of-care payments by QualChoice. Payer clients such as QualChoice can create their own bundle designs for the software. In addition, TriZetto’s solution includes pre-configured common episodes of care that have been defined by national entities, including the Centers for Medicare and Medicaid Services and Integrated Healthcare Alliance of California. The solution pre-integrates with TriZetto’s core administration and network management systems, and is also designed to work with systems from other vendors.

QualChoice is the brand name for products and services provided by QCA Health Plan, Inc., and QualChoice Life and Health Insurance Company, Inc. QualChoice is an Arkansas-based health services company offering a comprehensive line of health benefit and ancillary products on both a fully insured and self-insured basis. The company has become a market leader in providing competitively priced managed care products and excellent customer support. Headquartered in Little Rock, Ark., the company is the second-largest managed care company in the state. It also operates an office in Springdale, Ark. For more information, visit .

TriZetto provides world-class information technology and service solutions that help payers and providers work more efficiently and to deliver better health. TriZetto solutions touch over half the U.S. insured population and reach more than 180,000 care providers. TriZetto helps healthcare organizations ; ; ; and compete to win in an emerging retail market. Payer solutions include , , and portal platforms, as well as , and . Provider solutions include real-time eligibility assurance and claims editing and that help providers get paid quickly and accurately. For more information, visit .


1. 2012 Arkansas Business of the Year, awarded by the Arkansas Business Publishing Group, in the 76-300-employee category, or Category III.