The healthcare industry is experiencing rapid change in how care is delivered, driven by a dramatic increase in information availability in the era of Big Data.
Health insurance claims data provides significant detail of healthcare services and drugs provided. Currently, 93 percent of US physicians are using an Electronic Health Record system, (up from 9 percent in 2008), driven by government incentives and penalties. With the emerging Internet of Things (IoT), there are new opportunities to advise subscribers and providers with even more relevant information and insights. This new digital age in healthcare gives health insurance providers more timely and useful access to billing, cost drivers, and clinical outcomes. However, access to these data streams is only the start to realizing the benefits data analytics can provide patients, providers, and insurers.
Elder Research can provide analytics consulting support throughout the journey—from assessing analytics strategy to managing the institutional challenges of integrating analytics into healthcare systems and processes. Making the analytic insights accessible to the subscribers, the providers, and the insurer in a timely fashion will continue to be a key differentiator among insurance providers.
Expert analytics for health insurance delivers a wide range of benefits, including:
- Identifying fraud, waste and abuse by service providers
- Reducing duplicate tests and services
- Alerting patients and doctors about dangerous drug interactions or improper dosages
- Detecting potential non-compliance with patient medication plans
- Assisting medical research in identifying disease prevention measures, more effective treatment techniques, and improved drug therapies
The savings from health insurance analytics solutions can be substantial for all parties involved. For instance, researchers at the Center for IT Leadership estimated that the Department of Veterans Affairs realized savings of $4.64 billion just from preventing adverse drug reactions. Successful insurers will use intelligent processes to accurately provide affordable and high-quality medical services to an expanding population of people requiring them.
Our clients—whether newly formed analytics teams or established pros—find that we help them understand their data, strengthen their teams’ abilities, and bring to the forefront basic and advanced levels of insights aligned to their needs. Examples of our healthcare insurance solutions include:
Improving Dental Provider Performance and Patient Outcomes
Elder Research provided analytics consulting services to assess the performance of Medicaid dental providers, including a team of clinicians and network providers with operational expertise. An analytics solution was developed to produce long-term savings by assigning new patients to providers having the highest quality care for the lowest cost. Claims data from hundreds of programs over 5 years in 38 states were used to model quality information for specific procedures among 22 million members. We created a Bayesian adjusted binomial “provider scoring model” incorporating standard quality measures established by the American Dental Association (ADA). The risk analytics model accounts for geographic and socioeconomic factors as well as clinical review results to adjust the scored results.
Detecting Health Insurance Fraud, Waste, and Abuse
Elder Research developed a predictive fraud detection model that scored and ranked Medicare and Medicaid dental insurance claims by risk. The solution generated leads with the highest potential return on investment for investigators and increased the fraud detection rate from 5% to 48% for the top 50 riskiest providers identified by the model. Having explainable scoring was a key component of success, since the model results would be used as evidence to warrant opening an investigation for providers identified as suspicious.