Fallon Plan Innovations

Let Fallon Health be your partner in health care

What is Plan Innovations?

Fallon's Plan Innovations program provides a range of services, including consulting and program administration, that will help your business create value, reduce costs, mitigate risk and reach your goals.

With more than 35 years of history in creating successful health care solutions, our vast experience and knowledge in commercial and government health programs, medical management, analytics, policy and strategy, sales and marketing, and compliance will ensure your success.

Who do we serve?

We serve health care companies and start-up organizations of all sizes across the nation by bringing our expertize to your vision.

What do we offer?

We provide a range of services, including consulting and program administration, as well as joint ventures, specializing in:

  • Medicare and Medicaid services
  • Medical Management
  • Risk and Financial Management
  • Administrative services
  • Medicare & Medicaid services
  • Medical Management
  • Risk & Financial Management
  • Administrative services

Medicare and Medicaid services

CashTake advantage of our experience in government health programs and our systems that are designed for these regulated and changing markets. We understand the unique inner workings of government payors and their rules and regulations.

We offer services in the following:

  • Program development – Medicaid, Medicare Advantage, PACE, Duals programs
  • Compliance – state and federal CMS applications
  • Model of Care development
  • HPMS interface
  • Readiness reviews and plan implementation
  • Pharmacy Part B & D
  • Network Development and Management
  • Staffing and Training

Medical Management

CashFallon was born from an integrated health care delivery system. We believe in a person-centered approach that optimizes the health of each individual in the least restrictive setting. We offer a full spectrum of integrated programs to ensure health and productivity at every stage of life. From building a comprehensive model of care to administering care programs, we are the experts in medical management.

  • Care Management
  • Population Management
  • Pharmacy Management
  • Utilization Management
  • Quality improvement and monitoring
  • Assessment tools
  • Data-driven analytics
  • Robust reporting

Our model of care programs have consistently received above a 94% approval rating from CMS.

Risk and Financial Management

CashThe past few years have been an economic challenge for most industries, including health care. Statutory and regulatory changes at both the state and federal levels add to those challenges. With Fallon’s expertise in financial and risk management, we can help you achieve growth and profitability.

We specialize in:

  • Revenue optimization
  • Risk adjustment data collection and submission
  • Documentation audits and provider education
  • Hierarchical Condition Category (HCC) coding
  • Risk sharing relationship development
  • Underwriting and pricing
  • Actuarial analysis
  • Medical economics
  • Reporting and analytics
  • Trend development
  • Prescription drug event/Part D management
  • CMS financial bid audits

Administrative services

CashFallon continues to invest significantly in capital projects that improve infrastructure, products and services, including a state-of-the-art claims adjudication system, member web tools, and a cutting edge reporting package. We leverage these tools for our partners to seamlessly run the back office of your business.

These third party administrative services and business processing services are flexible and customizable for all plan types:

  • Network management and administration
  • Health Plan Operations – Enrollment and Billing, Claims Administration, Call Center services
  • IT development and infrastructure
  • Medical management – Care management, Population Management, Pharmacy Management, Quality Improvement and Monitoring, Appeals and Grievances
  • Compliance
  • Accounting and Financial services
  • Revenue Optimization
  • Sales and Marketing strategy
  • Communications support
  • Medical informatics and analytics to help providers manage patients and the cost of care


How to learn more

To see how Fallon Plan Innovations can help your business, contact:

David Przesiek
Senior Vice President and Chief Sales Officer

Why Fallon Health?

  • 35+ year history in creating successful health care solutions across all health care markets
  • Pioneered the first Medicare Risk demonstration plan in 1980 and the first Medicare-Medicaid plan
  • The first health plan in the country to build and operate a PACE program in 1995
  • Implemented unique, customized plan options for our state’s largest employers

Learn more

To see how we can help your business, contact:

David Przesiek
Senior Vice President and Chief Sales Officer