In the dynamic environment of healthcare, it is more important than ever to reduce costs; to focus acquisition, retention and expansion tactics on high-value customers; and to identify patterns in claims. STATISTICA’s predictive analytics and reporting solutions for Health Insurance applications enable payers to utilize data about claims, policies, customers, and third-party data sources to improve underwriting decisions, detect fraud, detect trends in costs across various segmentations (e.g., diagnoses, treatments, providers, or geographies), and develop predictions of health efficacy based on diagnoses, treatments, and provider variables.
The Predictive Patient Management Solution provides these capabilities as shown in the following example.
StatSoft’s approach to engaging with a Health Insurance Company is very collaborative and results-oriented. StatSoft’s predictive modeling, analytics, and reporting solutions are designed to empower your company’s personnel. The StatSoft team works with your company’s key stakeholders to understand current personnel, processes, and systems. The STATISTICA solution is configured to fit and augment your company’s current capabilities. The collaboration begins with an assessment and agreement on business goals and the way that the results from the use of the STATISTICA solution will be measured. From that starting point, StatSoft and your company agree on prioritization and an approach to incremental investment that matches the expected and achieved payoffs.
- Healthcare Fraud: The STATISTICA solution for fraud detection augments current rules-based approaches (such as duplicate detection and invalid diagnosis-treatment combinations) to identify patterns in fraudulent claims to uncover new previously unknown types of fraud.
- Healthcare Efficacies and Outcomes: Today, there is an increased focus on healthcare outcomes. Identifying the factors (e.g., provider, length of stay, treatments, etc.) that impact costs and efficacy empower initiatives to reduce costs and grade providers.
- Preventative Healthcare: Predictive modeling of patient characteristics, disease onset, treatments, costs, and other variables provides valuable information for preventative healthcare programs to improve quality of life and reduce costs.
- Trending Costs: The STATISTICA Analytics platform provides flexible reporting for the ongoing monitoring and flagging of the expected versus actual frequencies and costs broken down by any number of segmentations: geography, age, provider, diagnosis, treatment, etc.
- Sequence, Association, and Link Analysis: Identify patterns in the combinations of diagnosis, treatment, and provider codes.
- Real-time Predictions and Integration with Claims Management Systems: The STATISTICA Solution is optimized for performing real-time predictions for supporting instant underwriting decisions or evaluating a claim as new information is made available.
- Reporting: Aggregated summary reports and configurable dashboards provide valuable information both to management and for tracking key performance indicators related to each functional area.
- Reason Codes: In addition to predictions and recommendations, the STATISTICA solution provides information about the reasons for the decision both for the awareness of key personnel and regulatory reasons, when applicable.
- Integration with Data Sources: The STATISTICA solution simplifies access to data from your company’s customer database, policy database, claims database, and third party data sources.
- Data Preparation and Management: Data in databases are rarely ready for analysis. STATISTICA includes all of the necessary recoding, transformation, and data aggregation procedures for preparing these data for analysis and scoring.