Enhancing premium restoration in four steps

Today, more than 22 million seniors and people with disabilities choose a Medicare Advantage plan, and enrollment is projected to increase to an all-time high of 24.4 million this year1. Do you have insight into how much revenue your plan might be losing in underpaid premiums?

Ensuring accurate premium payments for your Medicare Advantage members requires the right people, processes, and technology to identify your potential for premium restoration. It all starts with data. By integrating data sources and viewing eligibility data holistically, you can easily identify members with the greatest propensity for inaccuracy: those requiring Medicare Secondary Payer (MSP) validation and those diagnosed with end-stage renal disease (ESRD).

Here are four steps you can take to capture underpaid premiums:

#1: Identify members with premium restoration potential

The undisputed first step in capturing underpaid premiums is identifying those members with premium restoration potential. Our experience shows that an average of 4% of Medicare Advantage members have open MSP records, and 50% of those records have premium restoration potential. By identifying members with MSP or ESRD, your plan can ensure those members are accounted for in MMRs and in payments from CMS.

#2: Improve process efficiencies

When analyzing open MSP and ESRD occurrences, your plan needs to identify and prioritize those that require investigation. By allocating scarce resources to the activities that will have the greatest impact on the bottom line, you can ensure that dollars and staff time are spent wisely and efficiently.

#3: Monitor the financial impact

As premium restoration becomes more complex and when resources are limited, sophisticated monitoring is needed to achieve the results your plan expects. With a proactive approach to monitoring premium restorations, you will want to forecast how many dollars will be added to the premium check, uncover whether you have received every month of restored premiums, and maintain an audit trail to validate the outcomes and steps taken to correct inaccuracies.

#4: Maintain ongoing premium restoration activities

Given the impact it can have on your bottom line, the premium restoration process must be maintained on an ongoing basis. By ensuring payment accuracy throughout the year, you can capitalize on significant revenue opportunities month after month, year after year.

Discovery’s data analytics combined with our deep understanding of CMS eligibility rules can help your plan unlock the hidden value in your data and collect the full value of premiums owed.

Discovery Health PartnersEnhancing premium restoration in four steps
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eBook: Restoring millions for your Medicare Advantage plan

eBook: Restoring millions for your Medicare Advantage plan

Correctly paid Medicare Advantage premiums are a critical source of revenue for many health plans

Unlock the hidden value in your data to identify root causes of errors and collect the full value of premiums owed to your plan.

Download our eBook and find out how a Premium Restoration strategy can help you:

  • Identify members with premium restoration potential
  • Improve process efficiencies
  • Monitor the financial impact
  • Maintain ongoing premium restoration activities

Discovery Health PartnerseBook: Restoring millions for your Medicare Advantage plan
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Restoring Medicare premium revenue during COVID-19

Medicare Advantage enrollment and the number of confirmed COVID-19 cases are on the rise. According to the Centers for Disease Control and Prevention (CDC), older adults and individuals who have health conditions like heart, lung, or kidney disease may be at a higher risk for complications.

Your Medicare Advantage plan relies on the Centers for Medicare and Medicaid (CMS) for information regarding other health insurance and certain health conditions. When this information contains errors, it affects your bottom line. For many Medicare Advantage plans, the losses can be more than they realize.

What can your Medicare Advantage plan do to maximize its financial performance during these challenging times?

You can begin to recover the premium dollars owed to your health plan by performing a retrospective review of eligibility data. Going back seven years, you can review your monthly membership report (MMR) files to look for indications that the health plan is owed additional premium reimbursement for certain members.

What are the top reasons for missed premium restoration cues?

There are several cues that a plan may miss when it comes to premium restoration:

  • Incomplete data aggregation from the plan’s IT department
  • Inaccurate member questionnaire data
  • Section 111 reporting inaccuracies by commercial plans
  • Inability to completely or accurately validate a member’s other insurance
  • ECRS Web rejections that should actually result in premium reimbursements

Finding the causes of these missed cues can be difficult. Would you even know if your IT department is sending you incomplete data? What if you cannot get another insurer to validate eligibility information for a member? If CMS denies a seemingly legitimate eligibility update, do you know how to overturn that?

How Discovery can help

Discovery Health Partners can strengthen your premium integrity efforts by taking a closer look at Medicare Secondary Payer (MSP) validation and members with end-stage renal disease (ESRD). A recent analysis by S&P Global Ratings states that COVID-19 will end up costing U.S. health insurers more than $90 billion in medical claims.1 More than ever, it is important for plans to chart a course for transformative action that not only protects their premium revenue but also protects their workforce. With more individuals working from home and being allocated to support critical COVID-19 initiatives, Discovery is ready to continue working diligently on behalf of our health plan clients to identify eligibility issues and premium reductions.

We have helped clients restore millions with our Medicare Secondary Payer Validation solution:

  • $2.1 million for a 20,000-member regional plan
  • $16 million for a 30,000-member Midwest plan
  • $5.7 million for a 200,000-member Blues plan

In addition, our ESRD Premium Restoration solution has helped clients restore:

  • $6.5 million for a 160,000-member Medicare Advantage plan across a two-year engagement
  • $4 million for a 230,000-member Medicare Advantage plan seven months after implementation
  • $3 million for a 100,000-member Medicare Advantage plan in 12 months

The amount of potential restoration opportunity is a function of four parameters:

  1. Successful validation of inaccurate records
  2. Number of months of restoration opportunity for each incorrect record
  3. Average monthly restoration amount
  4. CMS acceptance rate of corrections submitted

Contact Discovery Health Partners today to find out how we can help you with your premium restoration efforts as your health plan navigates the impact of COVID-19.

Access the latest COVID-19 information and guidelines from CMS.

Jeffrey MartinRestoring Medicare premium revenue during COVID-19
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Four tips for balancing the effects of Medicare Secondary Payer

Medicare Secondary Payer (MSP) is a multi-pronged issue for Medicare Advantage plans. If plans aren’t monitoring the effects of MSP on medical and pharmacy claims as well as premiums from CMS, they could be hurting their bottom line—to the tune of millions of dollars. MSP also introduces compliance responsibilities that plans must regard or else face possible consequences.

This requires a balancing act to ensure primacy information is correct for members with other insurance and to verify that claims are paid and premiums are collected in accordance with the member’s primacy.  Plans should work to identify inaccurate primacy information and build processes that can help correct these errors so they can ensure accurate payments all around.

Let’s look further at each area.

Premium

It’s important to realize that CMS primacy information is not always correct. Medicare Advantage plans should be reviewing CMS information each month to verify primacy to identify underpaid premiums as well as overpaid premiums.

What’s your motivation to verify premium underpayments? Your bottom line! Underpaid premiums often cost health plans more than they realize, and, in fact, Discovery Health Partners has recovered more than $200 million in underpaid premiums for Medicare Advantage plans. When the MA plan moves from secondary payer to primary payer for a member, the plan can recoup underpaid premiums going back 72 months. This adds up quickly!

On the other hand, CMS mandates that plans repay premium overpayments within 60 days. Obviously, this is required to stay in compliance, so plans need to ensure they are checking for CMS overpayments as well.

As plans work to identify and correct primacy errors, we always advise them to do a root-cause analysis to determine why dollars were taken from the plan and identify the entity that “took” the dollars. For example, was it due to a Section 111 reporting issue? You can see this on a quarterly basis if you have constant flip-floppers (members for whom you already corrected primacy but who show up again later as secondary). This could indicate a problem on the commercial side of your own plan.

Once you identify the owner of the problem, you can work with them to make corrections. And you can prioritize the work by which entity or problem affected the most dollars for your plan.

Claims

The financial impact of incorrectly paid claims due to MSP is not as great as the premium impact, but it’s still a worthy effort to verify claims that can return dollars to your plan. As you know, primacy order determines how claims should be paid.

As you update primacy information based on a monthly review of CMS files, it’s important that MSP and claims specialists work closely together. As primacy order changes, claims specialists can make sure claims get adjusted and reviewed. They also should make sure that claims systems are updated in order to pay claims correctly to providers.

You also can recoup overpaid claims (claims that you paid as primary but should have paid as secondary). Usually, you can go back 12 or 18 months to adjust claims and recoup dollars—it depends on contracts with providers or state regulations—which can add up to millions of dollars. It seems that CMS is paying closer attention to how claims are paid and if they follow the order determined by the plan, so if you haven’t focused on this before, now is a good time to change that.

It’s important to look at the full picture across premiums and claims—if you’re getting a reduced premium and paying claims as primary, then it’s a double hit for your plan. If you can correct both, it’s an even bigger improvement to your bottom line.

Pharmacy

Part D plans have an obligation to verify primacy and ensure that member drug benefits are available to them when they need them. Plans that use a pharmacy benefits management firm (PBM) to manage pharmacy claims should be sure to share primacy updates with them and verify that they actually use that information. The PBM should pay claims based on recent verification on the medical side.

It helps to ask PBMs about their processes and how they use the information you give them. Ask them to map out the process so you can see that payments will be correct based on the information you share. Again, CMS is looking at this to ensure pharmacy claims are paid accurately.

Tips and tricks

If you’re uncertain about the performance of your MSP process, keep these tips in mind:

  1. Make it an ongoing process. Member primacy is constantly changing, so you have to keep on top of your monthly reviews.
  2. Check everything. As I said before, CMS may have inaccurate primacy information, so you have to double check that each month. Likewise, make sure your recovered premiums match your expectations each month—if you expect 60 months of premiums back, make sure you get the full 60 months.
  3. Assess. Get to root cause of errors and make sure updates get made.  For example, look for constant flip flops for indications such as Section 111 reporting problems. Also, review TRR 245 and 280s, which notify the plan of a member’s MSP status turning on and off. By reviewing and verifying the daily 245, you can avoid losing dollars instead of recouping after the premium has been reduced.
  4. Validate. Other insurers are your best source of validation information. Consider keeping a database of other insurer phone numbers to make research easier and faster. Use all the information available to you—member surveys, Section 111 responses, CMS reports, etc.

For more on this topic, view our on-demand webinar, Walking the line: balancing claims, premiums, and compliance for MA plans.

 

 

Discovery Health PartnersFour tips for balancing the effects of Medicare Secondary Payer
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MSP Validation momentum continues for Discovery with new wins in Q3

Blue Cross and Blue Shield plans headline new client roster

 

ITASCA, IL—October 24, 2017 – LaunchPoint division Discovery Health Partners, a provider of payment and revenue integrity solutions for healthcare payers, added three Blue Cross and Blue Shield plans in Q3 to its growing roster of clients. More than 50 health plans, including 4 of the top 10 insurers, are Medicare Secondary Payer (MSP) Validation clients.

Honored two years in a row as a top 100-finalist in the Chicago Innovation Awards, MSP Validation helps Medicare Advantage plans recoup millions of dollars to their bottom lines by ensuring the accuracy of healthcare premiums paid by Centers for Medicare and Medicaid Services (CMS) for members with other health insurance. To date, Discovery has restored more than $200 million in underpaid premiums for its clients, including more than a dozen Blues plans.

MSP Validation analyzes plans’ open MSP records, validation of primacy, ECRS submissions, response monitoring, and premium reconciliation. The solution is typically delivered as an outsourced business process with Discovery experts managing the entire process on behalf of the client. It is often provided as a supplemental offering that complements clients’ existing efforts to help restore more. Clients can also subscribe to the service as cloud-based software to manage the MSP process in-house with their own staff. Many choose to take over ongoing maintenance after Discovery manages the initial restoration effort.

About Discovery Health Partners

Discovery Health Partners, a division of LaunchPoint, offers payment and revenue integrity solutions that help health payers improve revenue, avoid costs, and enhance the member experience. We offer a unique combination of deep healthcare expertise and analytics-powered technology solutions to help our clients improve operational efficiency, achieve financial integrity, and generate measurable results.

 

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Discovery Health PartnersMSP Validation momentum continues for Discovery with new wins in Q3
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Discovery MSP Validation achieves $200M in premium restorations

Milestone reflects accelerating momentum in new client growth

 

ITASCA, IL—August 29, 2017 – LaunchPoint division Discovery Health Partners, a provider of payment and revenue integrity solutions for healthcare payers, has restored a record $200M in premium for its health plan clients through its MSP Validation solution. Honored two years in a row as a top 100 finalist in the Chicago Innovation Awards, MSP Validation helps Medicare Advantage plans recoup millions of dollars to their bottom lines by ensuring the accuracy of healthcare premiums paid by Centers for Medicare and Medicaid Services (CMS) for members with other health insurance.

“We can deliver significant premium restoration in a matter of months, which is continuing to drive strong interest in MSP Validation among health plans,” said Paul Vosters, Discovery president. “Few payment or revenue integrity solutions can boast of such a fast ROI,” he added. Discovery added five new clients in Q2 of 2017, covering in sum 346,000 Medicare Advantage members. New clients include such highly respected health plans as Tufts Health Plan, Geisinger Health Plan, and UCare. More than a dozen new MSP Validation clients have joined the Discovery client roster since the first of the year.

MSP Validation includes the analysis of open MSP records, validation of primacy, ECRS submissions, response monitoring, and premium reconciliation. The solution is typically delivered as an outsourced business process with Discovery experts managing the entire process on behalf of the client. It is often provided as a supplemental offering that complements clients’ existing efforts to help restore more. Clients can also subscribe to the service as cloud-based software to manage the MSP process in-house, with their own staff. Many choose to take over ongoing maintenance after Discovery manages the initial restoration effort.

 

About Discovery Health Partners

Discovery Health Partners, a division of LaunchPoint, offers payment and revenue integrity solutions that help health payers improve revenue, avoid costs, and enhance the member experience. We offer a unique combination of deep healthcare expertise and analytics-powered technology solutions to help our clients improve operational efficiency, achieve financial integrity, and generate measurable results.

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Discovery Health PartnersDiscovery MSP Validation achieves $200M in premium restorations
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Discovery to speak at MedAdvantage Operational Finance Summit

Session by Discovery Health Partners’ Kathleen Cortez to set the stage for understanding payment integrity’s role and value

 

ITASCA, IL (July  11, 2017) –Discovery Health Partners, a provider of payment and revenue integrity solutions for healthcare payers, will co-sponsor and speak at the Medicare Advantage Operational Finance Summit on July 18-19, 2017, in Chicago. Hosted by Healthcare Education Associates and RISE, the conference brings together Medicare Advantage executives from operations, compliance, membership, and other areas to discuss enrollment and membership operations, accounting and reconciliation, and comprehensive payment integrity.

Discovery Vice President of Operations Kathleen Cortez will kick off the payment integrity track with a discussion of the role and value of a comprehensive payment integrity program for the Medicare Advantage plan.  “Kathy does an excellent job helping stakeholders understand what payment integrity is, how it fits within the MedAdvantage plan, and what value it delivers,” said Paul Vosters, Discovery president.  Payment integrity addresses the accuracy of the transaction occurring between health payer and provider.  It ensures that the health claim is paid correctly—by the responsible party, for eligible members, according to contractual terms, not in error, and free of wasteful or abusive practices.

The session also includes a discussion of payment integrity best practices as gleaned from almost a decade of Discovery’s experience helping health plans manage such programs.

Discovery Health Partners is a member of RISE, the Resource Initiative and Society for Education, an organization dedicated to ongoing outreach and education for health plans and providers.  Discovery frequently speaks and exhibits at conferences managed by RISE affiliate Healthcare Education Associates.

About Discovery Health Partners

Discovery Health Partners, a division of LaunchPoint, offers payment and revenue integrity solutions that help health payers improve revenue, avoid costs, and enhance the member experience.  We offer a unique combination of deep healthcare expertise and analytics-powered technology solutions to help our clients improve operational efficiency, achieve financial integrity, and generate measurable results.  More information about our solutions, including Coordination of BenefitsEligibilityMedicare Secondary Payer Validation, and Subrogation is available at https://www.discoveryhealthpartners.com.

 

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Discovery Health PartnersDiscovery to speak at MedAdvantage Operational Finance Summit
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Discovery Health Partners sustains momentum in Q1 with MSP wins

Strong business case and quick ROI keep demand strong with health plans of all sizes

 

ITASCA, IL (June 26, 2017) – LaunchPoint division Discovery Health Partners, a provider of payment and revenue integrity solutions for healthcare payers, added 5 clients in Q1 of 2017 for its Medicare Secondary Payer (MSP) Validation solution. This strong success sustains the strong momentum of the last three years during which 35 health plans chose Discovery’s MSP Validation solution, representing a third of the Medicare Advantage market.

Discovery Health Partners, honored two years in a row as a top 100 finalist in the Chicago Innovation Awards, helps Medicare Advantage plans recoup millions of dollars to their bottom lines by ensuring the accuracy of healthcare premiums paid by Centers for Medicare and Medicaid Services (CMS) for members with other health insurance. In the last three years, Discovery has restored more than $150 million in underpaid premiums for its MSP Validation clients.

“Clients love this solution because the ROI can be realized in a matter of months,” said Paul Vosters, Discovery president. “While the larger plan has the most to gain given their larger member base, there is clear advantage for Medicare Advantage plans of any size,” he added. Q1 new clients include both small, mid-sized, and large Medicare Advantage plans, including Upper Peninsula Health Plan, PacificSource Health Plans, and one of the top 5 health plans in the U.S.

MSP Validation includes the analysis of open MSP records, validation of primacy, ECRS submissions, response monitoring, and premium reconciliation. The solution is typically delivered as an outsourced business process with Discovery experts managing the entire process on behalf of the client. It is often provided as a supplemental offering that complements clients’ existing efforts to help restore more. Clients can also subscribe to the service as cloud-based software to manage the MSP process in-house, with their own staff. Many choose to take over ongoing maintenance after Discovery manages the initial restoration effort.

About Discovery Health Partners

Discovery Health Partners, a division of LaunchPoint, offers payment and revenue integrity solutions that help health payers improve revenue, avoid costs, and enhance the member experience. We offer a unique combination of deep healthcare expertise and analytics-powered technology solutions to help our clients improve operational efficiency, achieve financial integrity, and generate measurable results.

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Discovery Health PartnersDiscovery Health Partners sustains momentum in Q1 with MSP wins
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A second look at underpaid CMS premiums could restore millions

 

Premium loss due to Medicare Secondary Payer (MSP) has more impact on the financial bottom line of a Medicare Advantage (MA) plan than many people realize. Though MA plans are on the task – attempting to find and correct errors in member eligibility and CMS premium payments – most are still missing millions of dollars due to hidden challenges in the process.

For this reason, any plan could benefit from a supplemental “lookback” at their MSP files to ensure all the bases have been covered and premium revenue has been maximized. This simply means looking back through the plan’s MSP, MMR, and member eligibility files to look for cues that the MA plan is owed additional premium reimbursement for certain members, either because of inaccurate eligibility information or because of a process issue that was unable to correct eligibility information and restore the premium.

Why supplemental MSP Validation is necessary

The reasons that these cues may have been missed in a first pass are varied and often include:

  • Incomplete data aggregation from the plan’s IT department
  • Section 111 reporting inaccuracies by commercial plans
  • Inability to completely or accurately validate a member’s other insurance
  • Acceptance of ECRS Web denials that should actually result in premium reimbursements

Some of the most common reasons plans are unable to identify or restore underpaid premium are out of the control of the department that is managing MSP validation. Would you even know if your IT department is sending you incomplete data? What if you can’t get another insurer to validate eligibility information for a member? If CMS denies a seemingly legitimate eligibility update, do you know how to overturn that?

How supplemental MSP Validation works

Typically, when a MA plan does a “lookback” across its full MSP file, it can expect to see a spike in premium restorations over an initial validation period of about 4 to 6 months, often bringing in millions of dollars in additional premium revenue.  Restorations will then taper off as the plan maintains a best practices MSP program.

Discovery Health Partners provides a supplemental MSP Validation solution that complements MA plans’ internal efforts by doing this lookback for them.  Again and again, we find that even though most of these plans are working diligently to identify eligibility issues and premium reductions due to MSP, every one of them had been underpaid more than they realized.

In fact, in the last three years, we have recovered $150 million in additional premium restoration opportunities across all of our MA clients. These include plans of all sizes and maturity levels:

  • 100,000-member New York area health plan – $24 million
  • 30,000-member Midwestern health plan – $16 million
  • 20,000-member regional plan – $2.1 million

The amount of potential restoration opportunity for a MA plan is a function of five parameters. The variability of these parameters among our clients has resulted in a premium recoupment range of $11 premium per MA member on the low end to $419 premium per MA member on the high end.

  • The number of identified indications of other insurance on file with CMS for the plan’s MA members
  • The percentage of inaccurate records successfully validated
  • The number of months of actual restoration opportunity there is for each incorrect record
  • Average monthly restoration amount
  • CMS acceptance rate of corrections submitted

Check out our newest infographic, which highlights the impressive results MA plans of all sizes have had with a supplemental MSP validation solution that complements their ongoing internal efforts.  You’ll see why using an outside firm to help with this lookback can yield additional premium recoupment at no risk to your plan.

Paul VostersA second look at underpaid CMS premiums could restore millions
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Discovery Health Partners adds new healthcare clients

Demand for Medicare Secondary Payer (MSP) Validation solution drives growth

 

ITASCA, IL (March 14, 2017) – LaunchPoint division Discovery Health Partners, a provider of payment integrity and population risk management solutions for healthcare payers, added 16 clients in 2016 for its Medicare Secondary Payer (MSP) Validation solution.  MSP Validation, honored two years in a row as a top 100 finalist in the Chicago Innovation Awards, helps Medicare Advantage plans recoup millions of dollars to their bottom lines by ensuring the accuracy of healthcare premiums paid by Centers for Medicare and Medicaid Services (CMS) for members with other health insurance.  In the last three years, Discovery has restored more than $150 million in underpaid premiums for its MSP Validation clients.

“SummaCare’s experience with the Discovery team was an award-winning experience as their staff was well-trained and professional, provided great customer service, and most of all improved our financials through their MSP Validation process,” said Rick Alexsonshk, Manager, Financial Reconciliation, SummaCare, a regional health plan offering a full range of health insurance services.  “It was a totally enjoyable and profitable experience that I would recommend to other health plans!”

MSP Validation combines the expertise of healthcare payment integrity experts and powerful MSP software residing on Discovery’s Healthcare Analytics Platform. “Our proven process covers identification of open MSP records, validation of primacy, ECRS submissions, response monitoring, and premium reconciliation,” said Paul Vosters, Discovery President. “Not only does it deliver near-perfect premium restoration success within a matter of months, it also enables clients to correct inaccurate eligibility information so they receive correct premiums and pay claims correctly in the future.”

Discovery Health Partners is the market leader in MSP Validation, with more than 35 national and regional health plans on its client roster, representing a third of all Medicare Advantage plans with at least 5,000 lives. New clients in 2016 include Commonwealth Care, Health Alliance Plan of Michigan, Health First Health Plan, Vantage Health, and four Blue Cross/Blue Shield plans, among others. In Q1 of 2017, Discovery added one of the top 5 health plans in the nation to its roster of MSP Validation clients.

The MSP Validation solution is typically delivered as an outsourced business process with Discovery experts managing the entire process on behalf of the client. It is often provided as a supplemental offering that complements clients’ existing efforts to help restore more. Clients can also subscribe to the service as cloud-based software to manage the MSP process in-house, with their own staff.   Many choose to take over ongoing maintenance after Discovery manages the initial restoration effort.

About Discovery Health Partners

Discovery Health Partners, a division of LaunchPoint, offers payment and revenue integrity and risk management solutions that help health payers improve revenue, avoid costs, and influence member well-being.  We offer a unique combination of deep healthcare expertise and analytics-powered technology solutions to help our clients improve operational efficiency, achieve financial integrity, and generate measurable results.  .

 

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Discovery Health PartnersDiscovery Health Partners adds new healthcare clients
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