Insurance analytics in healthcare investigates the insurance claims data including the validity of submitted claims and determines the extent of the coverage it warrants. Analyzing claims is one of the most important activities for payers and consumes most of the resources. It is necessary to detect faulty and fraudulent claims and prevent losses for payers. Studies and research have revealed that inaccurate claims waste nearly $17 billion for payers every year. Analytics in insurance claims help payers filter out faulty or inaccurate claims and improve their revenues.
Fraudulent claims cost billions of dollars for insurance payers. But OSP can develop solutions for claims analytics in insurance to enable payers to place the right filters against their plans for identifying anomalies. Our solution will automate large parts of the assessment process to empower payers to analyze more claims faster and more efficiently. This will increase the number of fraudulent claims detected and save precious revenues for insurance payers.
OPS will build solutions for insurance claim analytics to enable payers to gather information about health plans and claims to determine risks better. Knowing the pattern of risks helps payers to create and modify health plans accordingly and streamline the entire process around claims and reimbursements. Knowing who might require what coverage based on relevant risk factors helps payers prevent excessive reimbursements and better control care costs.
Fraudsters are always looking for newer ways to game the system and get away with as much as possible. We can offer claim analytics to help insurance payers gather operational data on the claims they receive and assess the same to find anomalies. Subsequently, the insights gained from this enable payers to broaden the scope of their claim analytics and stay vigilant of newer tactics that might be used to obtain higher reimbursements.
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Claims analytics is the assessment of data from medical claims to identify useful insights. These insights enable insurance payers to optimize their operations and serve their stakeholders better.
Data about operations contains useful patterns and insights that reveal more about how the industry works. Evaluating risks, determining the treatment cost of chronic diseases, coverage through health plans, deciding premiums, and other vital decisions can be taken accurately by analysing long-term data from claims. This assessment helps payer companies to serve their stakeholders better through informed decisions.
In other words, data analytics is used to make better decisions and derive value for patients, providers, and payers.
1. Nature of claims – Medical claims can be for any one of the large number of medical services rendered by providers. It is important to factor this in when collecting claims data for analytics, as two or more claims even for the same disease may vary vastly.
2. Time – Depending on the nature of claims, they can take anywhere from a few days, some weeks, or even a couple of months to process. So it is important to glean usable data after processing has been concluded.
3. Data Integrity – The claims need to adhere to policies and follow the required regulations, be in the right format, and remain consistent with standards. This ensures that its assessment will reveal actionable insights.
4. Establish Parameters – Analyzing claims data would need to be done according to some parameters, which means that the objectives need to be clear. These can include assessing spending patterns, treatment patterns, frequency of admissions for particular diseases, and so forth. Data from numerous claims can shed light on these factors.
1. Cashless Claim
This is type of medical insurance claim where patients can receive treatment at a network hospital without paying out of their pocket. The claims are sent from the hospital to the payer, who pays it. The patients need to go to a hospital or clinic within the network and show the health plan card with a proof of identification.
2. Reimbursement Claim
In this type of claim, the patient could visit any medical center, which may or may not be in the payer’s network. After the medical services have been rendered, the patient pays out of his or her pocket and applies for a reimbursement from the insurance company. This could take longer as the patient’s bills, prescriptions, and other relevant documents need to be processed before the claim.
A claim is a bill sent by providers to insurance payers for medical services rendered to patients. It contains details of all the billable services that the providers provide.
A reimbursement is the payment made to providers by payers for the services provided to patients. The payment is based on multiple factors and so, the payers first process each medical claim to test its validity. If everything is found to be proper and compliant, the payers will reimburse the full or partial amount, depending on the health plan.
1. Reduction in Claims Fraud
This is one of the biggest advantages of claim analytics. Research and studies estimate that claims fraud costs billions to the healthcare industry. So, analyzing claims to identify anomalies or discrepancies helps payers prevent fraudulent claims from being accepted. The more the analytics software assesses such claims, the better it gets with time.
2. Reliable Risk Assessment
Identifying risk accurately is vital for payers as they can charge the premiums accordingly. This enables them to provide coverage for the members enrolled in their plans. Members who are likely to incur high healthcare costs are deemed higher-risk and so, would be charged higher premiums.
3. Improve Decision-Making
Assessing insurance claims provides fascinating insights about various factors in the healthcare industry. Things like spending patterns, medical services for conditions, frequency of clinical visits for diseases, and others are identifiable with claim analytics. Insights surrounding these factors, along with other, help payers make informed decisions.
4. Improved Revenues
Analyzing claims sheds light on risk, reimbursements, claims, and other operational workflows. This insight helps payers identify pain points in their organization and take steps to address them. Subsequently, this results in improved efficiency, lowered overhead, and reduced losses due to fraud. These benefits ultimately culminate in higher revenues overall.
When a patient goes to a doctor, the doctor attends to the patient and provides the necessary services in the form of tests, consultations, prescriptions, etc. The provider then proceeds to code these services to generate a claim to be sent to a payer. The claim is a summary of all the billable services rendered to the patient.
The payer assess this claim, verifies if the services were valid, and provides payment to the provider in the form of reimbursement. This payment depends on the coverage of the health plan. The payer also sends over an Explanation of Benefits (EOB) statement detailing the reimbursement provided corresponding to the services.
Claims adjudication in insurance is the process where the insurance company processes a claim to see if it is valid. If the claim is found to be valid, the insurance payer proceeds to settle the claim, or pay the entity that sent over the claim. However, if there are problems discovered with the claim during the adjudication, the claim is either denied or rejected depending on the situation.