How claims data technology becomes an expectation


Editor’s Note: We recently spoke with Anne Brunson, Vice President of Service Operations at Maestro Health, on the future of claims data, technology and self-financing.

1. How can self-funded employers leverage their health plan data?

Anne Brunson: One of the benefits of moving to a self-funded model is having better access to and the ability to derive insight from complaints data. With the help of an Independent Third Party Administrator (TPA), employers have access to their complaints and data regarding the services they have used, which helps the TPA and the employer identify cost drivers, tailor the plan to their members’ needs and predict what their claim expenses will look like.

For example, if your data shows you have a high percentage of preventable emergency room visits, this indicates that members are going there rather than to a doctor’s office or emergency care for primary and non-emergency care. . With this information, the employer could work with the APT to create disincentives in the plan, such as higher co-payments for unnecessary emergency room visits or educational materials for members on where to look for the vouchers. care at the right time, etc.

Related: Infographic: Trends in Self-Funded Group Medicare Plans

Usage and claims data like this can help employers better understand the needs of their members, where they need to provide additional resources, and how to tailor the plan to be as cost effective and accessible as possible.

Companies that are fully insured typically do not have this level of visibility into their costs and employee needs, which is why it is a unique advantage to move to a self-financing model.

2. How can employers who are considering self-financing access their data? What if they can’t access it?

A B: For a fully insured employer, it is best to go through their broker to obtain the information. While the insurer is unlikely to provide the claims data for analysis, it should be able to get specific reports, such as emergency usage and high dollar claims, for example.

3. What are some of the main features of healthcare and claims analysis tools?

A B: Just as companies expect sophisticated and comprehensive tools for their marketing and business efforts, employers want technology that enables teams to make important decisions about a company’s health plan. Some key features of these reporting tools include examining cost drivers, plan usage and member care needs / gaps and high cost claims trends. Make sure the tool has the ability to explore, as well as the ability to create cohorts within the participating population. Most importantly, make sure that the employer and the broker can access the reporting tool themselves. They can choose to let the TPA run the reports, but it’s their data and they should have access to it on demand. Due to healthcare data regulations and the complex nature of health claims, it is crucial to have tools that can extract valuable information with the correct benchmarks or prices. This will help PTAs and employers design the right benefit plan for their employee base and reduce unnecessary costs.

4. What kinds of programs can employers put in place?

A B: Employers can work with their APT to analyze data and extract valuable information to meet cost drivers and the health needs of their workforce. For example, programs that offer easy-to-use dashboards and tools are preferred for stakeholders to convert complaints into one-off visits, identify incomplete data, and categorize vendors to identify cost trends. PTAs are able to help employers extract this data to make recommendations for cost reduction or management of care. With easily accessible information, employers can create more personalized health plans, meet employee clinical care needs, and reduce organizational costs.

5. Why is it not common to provide employers with the history and data of their members’ claims?

A B: Companies that are fully insured do not have the ability to see past claims, trends and costs associated with regular claims results, since the insurer does not provide the information. Large insurance companies use claims data in aggregate and do not look at it on a group-by-group basis. By switching to a self-funding model with the help of a TPA, employers have access to their claim data and can really see how the costs are distributed.


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