Commercial Health Plans improve margins by managing their administrative costs as well as their medical costs. For plans in the government sponsored healthcare space, they do so by controlling their administrative costs and not going over the 85% limit of medical costs. In both these cases, the common thread is controlling administrative cost.
At most for healthcare payers, analytics is the fiefdom of the actuaries. They slice and dice claims receipt and payment data, demographic information to determine where the dollars are being spent and which product is making the most money.
Managing administrative costs is a combination of daily meticulous planning as well as exercises in brute force (like cutting headcount at the expense of throughput and quality) – a lot of it based on knowledge gained by years of experience and post-facto dashboards. There is very little predictive analytics being used by operations executives.
Operations organizations at payers are struggling to answer some of these questions every month, quarter or year:
1. What capacity do we need in our mailroom and data entry centers for open enrollment?
2. Do we have enough call center agents to answer calls for a particular product next week – have we considered all the claim denials over the last one month?
3. Are we doing efficient pre-pay claims audit by considering error trends, seasonality as well as provider profiles?
There is so much to gain by operations organizations using smart analytics – be it descriptive, diagnostic or predictive.
The problem of integrating heterogeneous operational data sources across multiple platforms and
organizations has been one of the primary barriers to building an efficient operations analytics platform.
Operations data sources can vary from widely-used, standards-compliant products to custom data formats particular to a platform, for example claims data can be in a completely different format from the authorization data from a care management system.
In this whitepaper, “Moving Beyond the Dashboards – Analytics in Health Plan Operations” we explore what are the options and strategies in using smart analytics by operations organizations.
You can read more here.