Healthcare Insurance Analytics
Insurance in healthcare is widely sought after, and has a large user base across the world, thanks to its universal usability. Unfortunately, tasks and procedures can bog down a typical insurance agent in routine activities and can lead to a lack of connection between on-ground and strategic direction. Healthcare Insurance Analytics comes in to bridge this gap, differentiating the wheat from the chaff. Here’s what you should consider that analytics offers.
Enrollment Metrics
- Member count trend.
- Details of the highest selling plan and least sold plan.
- Groups members preference by Demo, Geo, Age, and others.
- Shows the trend of how satisfied the users are with their current plan.
- Comparison with other providers.
- Identifying the target group and helps in marketing strategy.
Encounter Metrics
- The encounter is a meeting point for provider, physician, and member.
- Health plan success mostly depends on how the encounter was.
- Providers rating also depend on the encounter.
- Timeliness and Quality of the encounter will be measured against providers.
- Member provider encounter ratio based on service type.
Claims Metrics
- Core aspect if health care.
- Involves all three stakeholders – Insurance provider, Physician, and member.
- Claim count by type and status is an important KPI.
- Turnaround time for the claim should be less.
- Ties to Encounter, Payment, Member, and Provider.
Payment Metrics
- Healthcare financials deals with both AR and AP.
- AR – Premium amount paid – Needs to be validated with the subscriber count.
- AP – Deals with capitation amount and Claim payment.
- Payments for each provider and through different means have to be monitored.
- Reversals, adjustment, duplicate pay needs to be addressed.
Fraud/Abuse prevention
- Health care organization has its own share of Fraud and Abuse incident.
- Example of Fraud and Abuse - Duplicate claims, incorrect use of codes, suspicious activities by providers and members.
- It is tough to identify the fraud or abuse in health care and analytics will come to rescue.
- Trends of claims by provider against procedure code and member.
- The trend of member insurance usage.
Utilization Management
- Utilization Management deals with the member’s plan utilization and relevant approvals.
- UM works with the provider to authorize any care that has been given to members.
- Later it will be tied to claims for processing.
- Encounter, UM, Claim will go into hands.
- Trends of Authorization by type will help us to identify the number of UM analyst required.
Care Management
- Care management helps members stay healthier.
- Engages in giving back to society.
- Provides direction to members to mitigate their risks and lead a healthy life.
- The goal is to reduce the insurance spending and thereby reducing the plan costs.
Provider Management
- Providers are the most important stakeholders in the health insurance domain.
- Execute insurance delivery and provide competitive offerings to users.
- Negotiation new contracts, extending existing contracts and identifying fraudulent providers is the key aspect of Health Care industry.
