The healthcare industry is experiencing rapid change in how care is delivered, driven by consumer expectations, technological advances, continually rising healthcare costs, and a dramatic increase in information availability.
Healthcare information can be mined and insights extracted for improved patient outcomes and cost savings in the Operational, Financial, and Clinical Pillars of healthcare. Health insurance claims data and Electronic Health Records provide significant detail about healthcare services and drugs provided. With widespread use of wearable sensors and Internet of Things (IoT), there are new opportunities to advise subscribers, providers, and care givers with even more relevant information and insights. 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 in all pillars of the healthcare industry—from assessing analytics strategy to managing the institutional challenges of integrating analytics into healthcare systems and processes. Making insights readily accessible to clinical and business decision-makers will continue to be a critical differentiator for healthcare organizations.
Expert analytics for healthcare delivers a wide range of benefits, including:
- Improving outcomes of care and utilization of resources
- Developing quality performance metrics to improve service and reduce cost
- Increasing patient-responsible pay rate
- Identifying pharmacy and service provider fraud, waste and abuse
- Optimizing claim management
- Diagnosing disease and rate of disease progression
- Reducing opioid risk
Provider Performance and Quality Scoring Analytics
High-quality, high-value healthcare is foundational to achieving desired patient outcomes, attracting new consumers, retaining staff, and obtaining optimal reimbursement. Analyzing data on provider performance and the quality of care allows for review and adjustment.
We provide analytics consulting services to:
- Create data-driven provider quality scores
- Perform performance-based referrals and network creation
- Identify over- and under-utilization by providers
Accurately assessing provider performance allows 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 challenge health insurers. Healthcare fraud is hard to detect due to the variety of nuanced deceits employed, the fact that investigative evidence is often buried in text documents, and that there is often collusion among network providers.
- Provider Fraud, Waste, and Abuse: We identify questionable provider practices and prioritize work for investigators, then measure the impact of the actions taken to further reduce the losses and promote best practices among providers.
- Pharmacy Fraud, Waste, and Abuse: We detect and investigate prescription shorting, drug switching, drug diversion, drug recycling, kickbacks, and many other techniques used by individuals or networks to commit prescription drug fraud.
We use advanced data science and predictive modeling techniques to prioritize investigative caseload, improve efficiency of investigative resources, and maximize recoveries.
Healthcare Claims Analytics
Claims analytics 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 be accurately estimated and insurance adjusters optimally assigned. Claims workflow optimization and automation frees adjustors and investigators to work on the most difficult high-value cases. Our claims analytics work with your in-house team to uncover additional opportunities to reduce costs and loss ratios by:
- Improving underwriting risk management
- Increasing claims approval speed and accuracy
- Improving claims management resource utilization
Pharmaceutical and Biotech Analysis
We have deep experience helping pharmaceutical, biotech, and agricultural clients derive actionable insights from their clinical data. We have helped 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, we can help you make valuable data-driven decisions with your life sciences data.