HEALTHCARE PAYER ANALYTICS

Transcription

1 White Paper HEALTHCARE PAYER ANALYTICS HEALTHCARE PAYER ANALYTICS Drivers for Payer Analytics Payer Analytics Opportunities Benefits of Payer Analytics

2 Abstract Face of the healthcare industry is changing rapidly. Patient-centric services, the pressure to reduce cost and improve co-ordination are the major drivers for this change. The same goes with healthcare payers. Initially, the decision making was with the provider and payer. Now the scenario has changed completely. Customers are the decision makers and they are quite sensitive to healthcare costs, which pushes the payers and providers towards industry standard practices such as electronic transactions. To be recognized as an industry leader, payers must drastically change their business models in order to cater to the changes in the new environment. Payers have to look upon a number of aspects such as fraud detection, claims management, member engagement, clinical predictions etc. So, what can the payers do to improve their quality and to differentiate themselves in the industry. The answer is pretty simple Analytics. By deploying analytics, the healthcare payers can drastically improve their service more importantly in a cost-efficient manner. This paper will discuss the challenges and opportunities in healthcare payer analytics. Page 2

3 Drivers for Payer Analytics Patient Protection and Affordable Care Act Obamacare or the ACA, as it is commonly known as, was enacted to increase the quality of the health insurance, make it affordable to everyone, to reduce the costs and to lower the uninsured rate. After the ACA enactment, the percentage of uninsured adults significantly dropped, which means the burden on the payers increased significantly. This forced the payers to adopt to a strategy which would minimize the risk due to ACA. Payers ran after robust analytics solutions to get a better understanding of the risks associated with this. Analytics would eventually help them to model the risk better and would give them a better understanding of the risk environment and structure. Quality Assurance and Compliance Healthcare industry has become more patient-centric. The decision making no more resides with the payers and providers. So, the patient is more concerned about the quality of service offered. They are spoilt of choices and so it is essential for the payers to satisfy the consumers. Moreover, the payers have to comply with the quality standards pertaining in the particular country. To improve their quality and compliance, they are looking up to analytics. In few countries, based on the rating, payers get bonus payments. Page 3

4 Cost Reduction Cost is crucial in any industry and healthcare industry is no exception. Payers are looking down to cut down the costs at all possible levels. For this, they need to have an in-depth analysis of data from all levels, which could be done by analytics deployment. Challenges for Payer Analytics Data Integration Data is available in abundance and they come from different platforms. The challenge lies in integrating these data. Since they are from different platforms, there will be lot of integration challenges which include challenges pertaining to data format, type etc. Moreover, mergers and acquisitions in the payer industry make it even more complicated. Page 4

5 Data Governance Once the data is collected, the problem comes in managing the data i.e. to build a strategy for payer analytics. The issues include data sharing, ownership etc. The strategy has to be built upon on the payer application scenario. Clinical Data Access Most of the payers do not have complete access to the clinical data. This complicates the processing from the payers side. This has to be addressed before implementing an analytics solution. Payer Analytics Opportunities Fraud Analytics According to a recent study, healthcare industry loses around $250 billion in frauds. The reasons might be errors in data entry, verification error, faulty claims etc. To combat to these frauds and wastes, analytics solutions are implemented. According to industry estimates, for every $1 invested, analytics returns $16, which is really incredible and it emphasizes on the importance of implementing fraud analytics solutions. Claims Processing Healthcare payers are processing millions of claims every year and this number keeps on increasing exponentially. So, it is never easy to process these many number of claims manually, as incorrect processing leads to frauds. Analytics can chip in for processing the claims electronically, as it provides flexibility and agility, in addition to reduction in processing cost. Customer Engagement As mentioned earlier, healthcare payer services are becoming more customercentric, which means customer engagement is a crucial part. Payers have to do various things to retain the customers. Analytics can help payers to develop customized plans for a customer based on the claims history. Page 5

6 Clinical Care Management Almost all eligible patients are insured today. It is essential for the payers to analyze their medical records. Proper analysis will lead to improvised claims processing. Predictive analytics would help the payers to predict the development of chronic disease in a patient based on his/her medical records. Benefits Management Customer demand drives benefits plans. Other drivers include new delivery models and legislation. So, it is essential for the payers to concentrate on the benefit plans. This would increase the customer retention rate. Benefit plans can be common for a certain group of customers belonging to the same age group or same organization etc. Benefits of Payer Analytics: Automate the claims processing Reduce the processing cost Reduce fraudulent claims Increase customer retention Increase the processing rate Better analysis of clinical data Customized plans Page 6

7 Conclusion Healthcare industry is one of the fast growing areas and it is quite essential for us to keep with up with the pace of the industry growth. With the increase in number of claims being processed, use of analytics in payers domain is important to reduce the processing cost, minimize risk and to increase the customer engagement. Author Sujitha Jawahar Digital Consultant, SENSIPLE Sujitha is a part of Digital Consulting Team at Sensiple. She consults organizations on embarking their digital strategies.sujitha has completed her Engineering in Electronics and Communication and is a management graduate from NIT, Trichy. Her interests include advanced analytics and project management which would help in resource optimization. Page 7

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