HIT Think

How payers can gain insights from new data

The Healthcare Reform Act, also known as the Patient Protection and Affordable Care Act, is driving fundamental changes across all healthcare stakeholders, including payers, providers and plan members.

Payers have to compete in the individual market and differentiate themselves based on cost and quality of service, offering a good consumer experience while adhering to mandated Medical Loss Ratio (MLR) and benefit structure requirements.

So what can payers do to prepare for this change while avoiding an adverse impact to their bottom line? The good news is that the answers can be found within the treasure trove of information already available to them.

A confluence of regulatory mandates and significantly evolved technologies has resulted in rapid digitization of information on an unprecedented scale. Sharing and accessing information also has never been easier.

However, the availability of all this data doesn’t necessarily mean that payers know how to make the best use of it and prepare for the future. The big question is this: Are there tangible and meaningful benefits for all the players in the healthcare ecosystem, especially the consumer?

Many organizations are struggling to make effective use of available data. While larger corporations have the scale and wherewithal to get there, small to medium-sized entities have a long road ahead of them. However, all organizations, regardless of size, will have to find actionable insights from the data that is available to them if they want to remain relevant.

Here are three ways payers can leverage data in a meaningful and effective manner.

Improve operations and IT solutions
Payers and other organizations responsible for claims need to focus on what is important to their business. Follow the money trail to understand where revenue is coming from, what the expenses are and where they’re being incurred. Combine this insight with data points from systems, processing details to develop a deeper understanding of operations.

The analytics of today must be able to channel efforts directly to actionable items. Knowing the claims auto adjudication rate, first-pass resolve rate (FPR) or denial rate is good, but it’s better to know who and what is causing lower FPR or higher denial rates and determining the patterns of the top contributors to the causes over a period of time. Appropriate stakeholders can implement system enhancement initiatives and reduce manual effort significantly on an ongoing basis.

Study inbound phone calls and other customer touch points. Understand how well self-service functionality is supporting your organization. The systems of today track and log every detail of every transaction regardless of whether it takes place over the phone, web or mobile platforms. Knowing the top reasons why patients or clients make contact can really help to take a more proactive approach to resolving issues before they escalate.

It pays to be lean, if not mean. Ongoing improvements in operations and reductions in administrative expenses are going to be critical to meeting cost objectives and MLR, while remaining competitive in the marketplace.

Reduce fraud, waste and abuse
While no one can be sure of how much financial loss is incurred due to fraud, waste and abuse, estimates range from 3 percent to 10 percent of national healthcare spending, which puts it between $68 billion and $230 billion in real dollar terms, according to Blue Cross Blue Shield.


But now, sophisticated analytical tools and algorithms are able to uncover hidden patterns that were not distinguishable before. As an example, the ability to use geocoding to overlay the location of member, provider and drug store locations, along with a visual representation of transactions between them on a map, has helped data scientists uncover patterns that confound common sense, opening up new avenues of investigation.

Techniques such as predictive modeling also can help to determine whether a provider could have provided a certain service on a given day, or if a member could receive a given service based on other available data.

It’s important to pick up the low-hanging fruit and, at the same time, do the basics right. Take the utmost precautions while enrolling providers. Verify their credentials and linkages to organizations where they have vested interests. Use statistical analysis techniques to determine deviation in claims payments and variance from averages to determine high-risk recipients of services and payments.

As the methods scammers employ evolve, technology will eventually catch up. Payers must be ready with the right tools in their toolbox to deal with this on an ongoing basis.

Improve population health
Payers have a 360-degree view of members’ health profiles, compiling claims data from physicians, hospitals, pharmacies and labs. This information can be leveraged to identify and stratify the riskiest members according to their disease and acuity of condition. This enables payers to target intervention and perform disease management and case management, while carrying out active care coordination through the continuum of care.

Payers can monitor the progress of intervention and collect data to track progress. The same data points can be used to predict outcomes and develop an appropriate care plan. Integrating data from various sources to alert a case manager—such as information from nurse advice lines, ER visits or readmissions—can enhance effectiveness.

Making better use of the healthcare data that’s already being collected is pragmatic and sensible, and it has the potential to deliver tangible business benefits.

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