At health plans today, reports are often found in the form of spreadsheets – which offer a flat and siloed view of reimbursement insights. Analytics can be more informative when they have accurate real time data and provide multi-dimensional views. Health plans have a lot of data, and it is important to get the most out of it to drive informed decision making and positive change.
The Reimbursement Information Payers Need
It is important to fully understand how your health plan’s claims are performing during reimbursement. Having an overarching view of a health plan’s entire reimbursement use case will provide insights on where problems are starting and how they ultimately affect reimbursement. As a starting point, health plans should identify the areas that aren’t receiving enough information and identify blind spots. Additionally, it is helpful to have comparison data to flush out the areas where improvement is needed or has been needed for an extended time. Having reimbursement data in one place instead of siloed individual reports can help a health plan find and remediate issues faster.
The Big Issues
Health plans often struggle with issues surrounding provider education, medical economics, and finance. These issues may result in underpayments/overpayments or delayed claim adjudication resulting in late fees. When any issue arises, swift detection and resolution are imperative to ensure quality and accurate reimbursement, and prevention of abrasion between a health plan and its providers.
Highlighting Your Successes
It is just as important to understand the areas where your health plan is excelling. Maybe your health plan has recently cut down in over-payments. With this being the case, it is important for a health plan to understand what changes were made and if they can be applied to other places within reimbursement. Reflecting on effective and modern changes that positively impact reimbursement can be beneficial across a health plan’s claims ecosystem.
But what if …
Once areas needing improvement have been identified, it is important to simulate results before applying changes and answer the question ‘what if this change was made?’. This allows for health plans to make informed and confident decisions that will foster positive change into the claims ecosystem. A couple of examples include:
- Contract Modeling
Better Insights Lead to Better Decisions for Claims Operations
Predicting the financial and operational impact of pricing edits and configuration changes to claims has been a challenge for decades. But advanced business intelligence solutions from HealthEdge’s payment integrity platform, Source, allow health plans to eliminate the guess work and adapt claims operations with confidence.
The Source Analytics Module allows leaders to:
- Accurately assess the impact of changes before applying to a particular product, region or provider contract
- Avoid unnecessary overpayments
- Improve provider relations through accurate communication of a new policy’s impact
- Reduce internal effort needed to manage and review results
- Proactively adapt to policy and rate changes to remain in compliance
Learn more about Source Analytics here.