Combining Data Analytics with Expertise to Optimize Claims Performance Management

There’s a smart trend we’re starting to see that starts with a simple equation:

E + D = O

Where E=expertise, D=data, and O=optimization.

Carriers are starting to discover that without professional expertise to turn disparate data into actionable optimization and measurable intelligence, data is powerless.

With property and casualty being a dynamic and constantly evolving industry, carriers are recognizing the need to boost the results from targeted claims data analytics by combining the data with a consultative approach to claims management. This powerful combination changes the information landscape to help carriers strategize for optimal outcomes and stay a step ahead of foreseeable industry changes based off trending data.

Research shows that 82 percent of insurers are focusing on some strategic project related to enterprise data and analytics, which encompasses carriers seeking out resources that provide insights into big data. There’s new value in industry experts and consultants who know how to drive the value of medical claims data compared to industry benchmark data by interpreting and leveraging large data sets. Comparing data to industry benchmarks can identify untapped opportunities that result in claims management efficiencies and an effective overall cost-containment strategy.

The marriage between the two facets—data and expertise—is a powerful union that helps carriers:

Assess and influence claims processes at the most critical point, providing a proactive and impactful analysis
Develop additional analysis in order to uncover problems within the data and be able to visually present it with correlation
Reveal meaningful and actionable patterns and trends in data
Identify fraudulent activity and behavior

Let’s take a look at three cases that illustrate the value our combined data and expertise bring to a variety of scenarios. One area in particular where our Mitchell expert bench and analysis have shown to improve performance results is in identifying fraud.

1. First Party Fraud Detection

In a case within first party, our claims performance consultants found a number of physicians using fraudulent billing practices and, as with many medical fraud cases, a hunch usually begins at the adjusters’ desk—and it often involves some sort of severity. In this case, a couple of adjusters in an insurance company started talking about how a doctor started billing differently—more specifically, making charges on codes without rates. They soon realized they were experiencing the same issue.

In the particular state where this case took place, there are a handful of codes without associated rates. These are what are called unlisted codes. And when a procedure doesn’t have a rate, physicians are paid 80 percent of their charges. It was discovered that the doctors on these claims figured out the fee schedule, then inflated their charges enough so that when they were paid 80 percent of their charges, they received the full amount rather than at the fee schedule rate.

What happened next is eye-opening. We sent our medical coding experts and consultants in to analyze the data a little more, and we realized the fraudulent billing practice was pervasive across multiple claims. To give you a sense of the severity of the problem, amongst the many cases we examined, we found one carrier in particular was being overcharged $3 million annually!

Relying on data alone would not have uncovered this fraud. Leveraging our bench of medical coding experts and consultants with years of industry and coding experience to analyze our databank brought these once-hidden findings to light.

Through insights gained from this case, our product team was able to integrate a new functionality rule in our medical bill review solution to help identify these instances—helping to prevent the same fraud from happening again.

2. Third Party Drugs and Bill Administration Litigation Support

Utilizing custom data tools, our consultant experts can compare disparate datasets for various purposes. In one case, we were asked to provide litigation support for a third party claim. To set the background, this case involved third party drugs and bill administration. There are many providers on a third party claim, and oftentimes, these providers don’t talk to each other. Drugs, mostly opioids, are routinely administered throughout the patient’s course of treatment by multiple providers. This causes expenses to go up, and consequently, the patient is treated for longer periods of time, which results in a delay in a patient’s recovery.

Our approach was to mine through our large historical claims repository to extract prescription insights and trending benchmark data. With our clear data visuals that include a tool set, analysis and insights, we were able to reveal to the judge and jury—and have them clearly understand—that this particular patient was, in fact, being over medicated due to drug-seeking behavior.

Our team was able to offer key litigation support by clearly showing what the drugs were used for, displaying our findings using powerful data visualization tools to determine that this person was undeniably being over medicated and in addition, potentially selling the drugs because he was being prescribed this drug from many different providers.

Our litigation support team was able to make a positive impact on the case with a combination of expert analysis and development of the visual data tool set that clearly illustrated key insights and specialty novelties with supported conclusions.

3. Workers’ Compensation Fraud Pattern Detection

On the workers’ compensation side of the business, our expert team was approached by a third party investigation organization asking for help in identifying providers that fit a specific modus operandi (M.O.). What we identified was that a group of providers had purchased archaic, non-certified medical device machines and were coding and charging the payor in excess of $1,000 for a different procedure than the original intent of the device. Using the device, the providers were performing a “therapeutic procedure” — one normally costing on average between $40 – $60. We had our coding experts research the issue and explore the case in more depth. Not only did we find a pattern of providers using inappropriate codes, but they were using all sorts of different codes that were going under the radar so they could make it look like the codes fit within their scope of practice. We were able to help this third party organization testify with a list of correct codes and the appropriate costs associated with the codes.

Conclusion

Data analytics combined with a consultative approach and visualization tools can help to shine a bright light on important issues within the property and casualty industry. Utilizing data analytics, coupled with focused industry expertise and consultative guidance, provides an opportunity to measurably optimize claims management, thereby achieving greater operational efficiencies and more effective cost containment and litigation strategies.

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Photo courtesy of: Property Casualty 360

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