Claims Analytics for Health Plans: A Guide for CFO's

Health plans face financial decisions every day that impact their bottom line. What terms will make a new provider contract more beneficial? How should a new payment policy be implemented for Medicare Advantage or Commercial business? To answer these questions well, payers need solutions that enable them to overcome the limitations of their existing technology and leverage real-time insights for business decisions and negotiations.

But some health plans run on multiple core claims systems that use several disparate pricing, editing, and payment integrity point solutions to try to pay claims accurately. Claims administrators spend hours looking at data from disparate sources and compiling information.

Historically, claims analytics can be disjointed. A payer may need to export claims from multiple sources, then process them in multiple batches using a separate solution to get the analytical data they need. This back-and-forth process produces old information that cannot be relied on for accurate analysis. It causes delays for everyone involved, and if decision-makers do not have quality information in a timely manner, there is less confidence for those in medical management and contracting when they make crucial decisions for a health plan’s financial success.

It is time for health plans to invest in integrated systems that allow data, and therefore analytics, to land in one centralized place. There is an opportunity to simplify the entire payment ecosystem and seamlessly connect to multiple claims systems and third-party solutions. Rather than connecting individually with different systems for Medicare and Medicaid pricing or specialty systems like genetic testing, the data should be available in a single location.

To gain a competitive edge in the evolving health care market, health plan CFOs need access to real-time data and the ability to view and analyze all claims as they are processed. Imagine that you could look at scenarios quickly with accurate data and evaluate “what if” modeling to discover better ways to do business. This information can transform a business, delivering immense value — like predicting the potential savings from structuring a contract differently.

Financial decisionmakers need a modeling tool that can take claims from one provider and run those claims through another provider’s contract to see how they would have priced differently. Imagine heading to the negotiation table armed with this data. A simple payment term could hold up an agreement – on the surface, one might assume this would deliver a big financial hit, but what if the data said otherwise? What if the data showed that there would not be a significant impact? Then the payer and provider could quickly agree to a contract that satisfies all parties without a contentious debate.

With the right technology and business intelligence tools, payers can model and forecast different pricing scenarios. They can make customizations and edits to see how different pricing rules calculate down to the cent. Reliable, real-time, integrated analytics unlock new possibilities and enable complete business transformation.