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 healthcare 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 and healthcare providers.

Elder Research can provide analytics consulting support throughout the journeyfrom assessing analytics strategy to managing the institutional challenges of integrating analytics into healthcare systems and processes. Making the analytic insights accessible to the subscribers and the providers in a timely fashion will continue to be a key differentiator among healthcare providers.

Expert analytics for healthcare 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  

PROVIDER PERFORMANCE ANALYTICS

Successful healthcare providers must leverage intelligent processes to accurately provide affordable and high-quality medical services to an expanding population. Accurately identifying what is working well and what is not is essential to providing the best treatment, administered by the right provider for the correct condition, and at the lowest cost for each patient. Elder Research provides analytics consulting services to healthcare service providers to measure performance and enable them to meet the mandate of delivering more effective healthcare services at a lower cost.

HEALTHCARE FRAUD, WASTE, AND ABUSE ANALYTICS

Excessive or redundant medical services, medical coding errors, improper billing, as well as outright fraud, continue to be a significant challenge for health insurers.  Healthcare fraud, waste, and abuse analytics identify questionable provider practices and prioritize work for investigators, then measures the impact of the actions taken to further reduce the losses and promote best practices among providers.  Healthcare fraud is difficult to detect because of the variety of nuanced methods employed, investigative evidence is often buried in text documents, and there can be collusion among network providers. To maximize recoveries with limited investigative resources advanced data science and predictive modeling techniques are required.

POPULATION HEALTH ANALYTICS

Population health management is becoming increasingly important as healthcare gradually moves away from the traditional fee-for-service model and toward integrated care.  Public incentives and mandates are growing to better serve patients while reducing their overall healthcare costs.  To meet this critical objective population health analytics models patient outcomes as evidenced in historical data.  Predictive analytics identifies and prioritizes the best action to take with individuals to reduce costs and achieve better patient outcomes, resulting in better overall health for the population.

Healthcare CLAIMS ANALYTICS

Claims analytics provides many other benefits beyond identifying potential fraud, waste, and abuse. It can pinpoint subrogation opportunities and the likelihood of claim litigation.  With accurate risk measurement, low risk claims can be fast-tracked for settlement.  Insurance loss reserves can also be accurately estimated and insurance adjusters can be optimally assigned.  Predictive analytics enable workflow optimization and automation, freeing adjustors and investigators to work on the most difficult high value cases.  While most insurers already have some form of claim analytics in place, advanced analytics can yield additional opportunities to reduce costs and loss ratios.

Pharmaceutical & Biotech ANALYTICS

Elder Research has deep experience helping pharmaceutical, biotech, and agricultural clients derive actionable insights from their clinical data. We have applied advanced analytics to help organizations make the decision to develop or market new medical or wearable devices or to determine the efficacy of a new drug in the marketplace.  Drug or device, Elder Research can help you make data driven decisions with your life sciences data.

Case Studies

The savings from healthcare analytics solutions can be substantial for all parties involved.  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 solutions include:

Improving Provider Performance and Patient Outcomes

thumb-Elder_Research_Case_Study_Improving_Provider_Performance_DentaQuest-1.jpgElder Research provided analytics consulting services to DentaQuest 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. Read the Case Study

Detecting Health Insurance Fraud, Waste, and Abuse

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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. Read the Case Study

Optimizing Federal Workers Compensation Claims Approval

thumb-Elder_Research_Case_Study_Optimizing-Workers-Comp-Calims-Approval.jpgElder Research developed a data-driven risk assessment framework to triage Worker’s Compensation claims, prioritizing high risk cases for review and fast-tracking other cases to avoid manual review and adjudication. Claims that are routed to the fast track are assigned risk-based maximum payment limits for intelligent ongoing claims management. Read the Case Study

 

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