PROJECTS
Target Market
Medium to very large healthcare payers. The High Cost Claims System (HCC) is currently being reviewed and considered by several leading healthcare providers.
Business Need:
Healthcare payers are constantly requested by member to provide tools and expertise to identify areas of risk and cost savings and provide a course of action to help reverse that risk and keep costs within reason particularly with chronic cases. Many processes are still manual and the also current tools fall short since the relevant data is in various databases, data warehouses and data marts, and other data sources to provide an automated and holistic view of member’s claim. Additionally there is limited to no use of Predictive Modeling to help manage care earlier – and potentially prevent the costs incurred in catastrophic cases.
Project Summary:
The HCC System allows providers to report, review and manage member’s claim, particularly chronic conditions and the risks associated with them. The HCC system supports or provides the capability to respond to requests within 24 hours of receipt of the request
OVERALL PROJECT DESCRIPTION:
Create a capability that will allow for the on demand production of a “High Cost Claims System” that consolidates data & information from a variety of source data marts of the healthcare payer’s Data Warehouse to provide a holistic, meaningful view of healthcare payer’s member claims, inferential disease, episode of care, clinical, health risk and predictive health care & health risk data. The report needs to serve to support – or provide – the capability to respond to request for clinical context at a member level with-in 24-hours of receipt of the request.
Providing this type of High-Cost Claimant reporting experience to accounts will also be seen as a differentiator and market advantage for healthcare payers.
Further the HCC can reduce the number of highly manual, clinical summary requests submitted to Health & Medical Management (H&MM); address increasing demand for high cost research, and would reduce/eliminate inefficient manual efforts to support account, underwriting, and clinical requests.
The High Cost Claims System provides a holistic view of member claims, clinical and predictive data that is required for responding to member requests within 24 hours
There is a highly manual process for answering account, underwriting and clinical requests. This manual process involves running multiple data queries against different data sources and tables, and manipulating the data to analyze before responding to open questions
Prototype of the report has already been created using data queries and MS Excel. This prototype has proven that the data exists and that the data can be leveraged. Data Types included:
Enrollment & demographics
Claims costs, overall by type of service category + top providers & services & conditions
Listing of all facility admissions
Predictive modeling risk classifications: Score & key, contributing episodes of care
Engagement in health management activities: key authorizations for high cost services, identification for and enrollment in chronic condition management and case management interaction.
| DBR #1 | #1 – Front End | ||||||
| Ability to Statement | A front end that enables production of individual HCC reports, on demand and by batch – based on unique member, as identified below. | ||||||
| User Story & Completion Criteria |
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| Detail Requirements (Business Rules & Variables) | Requirements for an High Cost Claims System (HCC) Front End:
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| Other Considerations | No known other considerations |
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