As major reforms sweep healthcare and introduce new regulatory requirements, it’s vital for payers to ensure that they still offer consumers quality service at the right price. Balancing the need to address mandated Medical Loss Ratio (MLR) and benefit structure requirements with the need to meet consumer demands and stand out in the marketplace is tricky.
There are meaningful benefits to be found in the unprecedented collection and accessibility of data in the digital age. By digging into data, healthcare payers can find actionable insights that will help them adapt and strategize for future success. There are three major advantages that payers can realize by analyzing and acting upon the right data.
KMS can help you leverage and get the most out of your data.
Streamlining operations and IT
Where does your revenue come from? What are your expenses? It’s not enough to know your claims auto adjudication rate, or First-pass resolve rate (FPR). You need to learn about the underlying causes. Your analytics should lead directly to action, so you can find out why denial rates are soaring or FPR is falling and address it.
Since you log every aspect of customer interaction, study why clients get in touch. Is your self-service portal meeting their needs? Can you take steps to cater for those needs sooner, and resolve issues before they escalate? Streamlining your operations in the right way will help to cut administrative costs and potentially improve customer service at the same time.
Reducing fraud, waste, and abuse
A great deal of money is lost to fraud, waste, and abuse. We could be talking about 3% to 10% of national healthcare spend ($68 billion to $230 billion), according to Blue Cross Blue Shield.
This can be cut down through the use of analytical tools and algorithms. Extracting the right data and collating it can unveil previously hidden patterns and help to open up new lines of investigation to expose fraud. Predictive modeling can also deliver insights on service provision.
However, organizations should also make sure the basics are handled correctly, verifying credentials and performing analysis to uncover deviations from averages in claims payments to find high-risk recipients. Weeding out the scammers is an ongoing battle that requires vigilance, adaptability and the right technology.
Improving population health
With a complete picture of customer health, built from physicians, hospitals, pharmacies, and labs, there’s an opportunity to develop smart care plans that may circumvent risks. Predicting outcomes can help to identify problems early. Pooling data from ER visits, readmission and nurse advice lines can lead to more effective care.
Targeted intervention and active care coordination can make a real difference to customer health and simultaneously help payers to mitigate risk and reduce costs. Any improvement in customer health is a win-win for everyone.
There’s so much data available, yet many organizations are struggling to derive business value from it. The industry needs to stop and assess how it can leverage this wealth of healthcare data. It’s possible to meet the regulatory burden, cut costs, and improve the level of care with the right approach.
