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 pharmacy and service provider fraud, waste and abuse
  • Improving utilization of care
  • Optimizing management of claims
  • Developing quality performance metrics to improve service and reduce cost

PROVIDER PERFORMANCE and Quality Scoring 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 provider performance analytics consulting services to: 

  • Create data-driven provider quality scores
  • Perform performance-based referrals and network creation
  • Identify over-utilization and under-utilization by providers

Assessing provider performance provides 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 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. 

  • Provider Fraud, Waste, and Abuse: 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. 
  • Pharmacy Fraud, Waste, and Abuse: Detect and investigate prescription shorting, drug switching, drug diversion, drug recycling, kickbacks and many other techniques used by individuals or networks to commit perscription drug fraud.  

Elder Research uses advanced data science and predictive modeling techniques to prioritize investigative caseload, improve efficiency of investigative resources, and maximize recoveries.

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 claims 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, Elder Research claims analytics can yield additional opportunities to reduce costs and loss ratios by:

  • Improving underwriting risk management
  • Increasinge claims approval speed and accuracy
  • Improving claims management resource utilization

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.

Healthcare 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.

Results: The Outcomes model provided quality information for specific procedures over time and enabled DentaQuest to reduce the amount paid per patient by 25 percent in the pilot state and to increase revenue by more than one dollar per patient per month. 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. 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. 

Results: 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. 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.

Results: Claims examiners use the 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 and to distribute case load more effectively. The expected performance improvement include reducing the number of fast-tracked case decisions overturned by 39% and reducing total medical amount for missed denials by 25%. Read the Case Study


Improving Claims Approval Speed and Accuracy

thumb-Elder_Research_Case_Study_Text_Mining_Claims_for_Disability_Approval_Social_Security_Administration.jpgElder Research combined text mining with traditional statistical techniques to create an analytics solution for ranking disability claims for approval. For the Social Security Administration identifying claims for disability that met the requirements for approval was a time-consuming and error prone process. Some claims were taking over two years to be processed, much too long for very ill or elderly claimants. The challenge was to effectively integrate the data. 

Results: The solution allowed 20% of the claims to be approved immediately which in turn allowed the organization to focus their resources on the most challenging cases and ensure that all statutory requirements were met. Read the Case Study

 

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