MCO Member Enrollment Recovery

A Managed Care Organization (MCO) was facing major challenges with inaccurate and procedural disenrollments. The MCO had access to monthly disenrollment data and could identify irregular patterns, such as unexpected coverage losses among Supplemental Security Income (SSI) beneficiaries - a population that typically maintains continuous Medicaid eligibility due to their disability status. However, without the technical capacity to analyze large datasets, the MCO was unable to produce actionable evidence for the state to address these errors. As a result, wrongful disenrollments created coverage gaps for vulnerable members, disrupted continuity of care, and led to millions of dollars in preventable revenue losses.

Agilian’s team deployed advanced data scanning and cloud-based analytics to uncover irregular disenrollment patterns. Through targeted probes and retention accelerators, we enabled the client to detect and validate disenrollment errors, present compelling evidence for member reinstatement, and establish a repeatable process to prevent future occurrences.

Result: Within weeks, the MCO recovered over 50% of its monthly procedural disenrollments. They have been able to protect hundreds of members from losing coverage and save millions in revenue - all while improving continuity of care for high-risk populations.