Managing and mitigating medical claim costs: 5 key applications of big data
November 29, 2016
Nurse case management can have a clear impact on promoting quality care, reduced loss costs and return to work. Harnessing the power of big data can improve outcomes for injured workers and employers.
Healthcare costs account for more than three trillion dollars in spending, and medical costs continue to outpace inflation. When we dig into workers’ compensation claims data, we see that medical also outpaces indemnity costs. According to the National Council on Compensation Insurance, in 1981, 57% of workers’ compensation claim costs were driven by indemnity, with 43% of costs coming from medical. By 2015, the dynamic had shifted, with medical accounting for 58% of claim costs.
From a general healthcare perspective, the accessibility of rich data in electronic medical records (EMR) can help medical providers make more informed treatment decisions and improve the quality of care delivered to patients. Healthcare systems have started to recognize the value of patient data, as well as the risks associated with it, within their organizations.
While medical providers continue to move toward having key patient information available at their fingertips, employers and workers’ compensation insurers have a more limited view. General healthcare providers may focus on underlying conditions, while occupational medicine doctors will focus on work-related injuries. As a result, disjointed care may be provided to injured workers with unintended consequences (e.g., drug interactions and overdoses).
Even with this constraint, insurers can help injured workers and employers by leveraging the power of the robust data available. The ability to capture and aggregate key claim information, along with other integrated medical management solutions, can help promote quality care while also managing and mitigating medical costs.
Five key benefits of big data to help manage medical costs:
- Appropriate and accurate treatment and billing – Systematically bringing multiple data sources together (e.g., claims data, medical documents and bills and standards of care) can help verify compensability and medical necessity of all charges. Streamlining the ability to cross-reference this type of information can also help claims professionals more quickly identify when an injured worker’s recovery has plateaued so that they can proactively assist in the medical management of the claim.
- Timely and targeted intervention – Claim outcomes can be affected by a series of factors at different points in time. Predictive models, drawing on a variety of structured (e.g., date) and unstructured (e.g., claim notes) data points can help identify potential high-severity claims and notify claim professionals that a certain action or focused expertise (i.e., nurse case management) may be beneficial to the claim.
- Fraud, waste and abuse identification – The ability to analyze data across claims helps enable the identification of fraud, waste and abuse (e.g., providers who consistently use the costliest and highest levels of treatment). Thwarting these behaviors can positively impact customers’ loss costs and create opportunities for recovery.
- High-quality medical providers – Aggregated provider and claim data creates the opportunity to develop an outcome-based medical provider network designed to deliver quality care to injured workers and promotes early return to work.
- Distinctive risk insights – Benchmarking key drivers of medical claim costs can help customers identify challenges and opportunities to leverage claims best practices, appropriate medical management services and preventative Risk Engineering solutions.
Harnessing the power of big data can be an increasingly vital driver in improving healthcare outcomes for injured workers. With that said, it’s important to remember that the greatest benefit comes from an integrated medical management approach that draws on each of these applications.
The information in this publication was compiled from sources believed to be reliable for informational purposes only. All sample policies and procedures herein should serve as a guideline, which you can use to create your own policies and procedures. We trust that you will customize these samples to reflect your own operations and believe that these samples may serve as a helpful platform for this endeavor. Any and all information contained herein is not intended to constitute advice (particularly not legal advice). Accordingly, persons requiring advice should consult independent advisors when developing programs and policies. We do not guarantee the accuracy of this information or any results and further assume no liability in connection with this publication and sample policies and procedures, including any information, methods or safety suggestions contained herein. Past results and prior performance are not indicative of future outcomes. We undertake no obligation to publicly update or revise any of this information, whether to reflect new information, future developments, events or circumstances or otherwise. Moreover, Zurich reminds you that this cannot be assumed to contain every acceptable safety and compliance procedure or that additional procedures might not be appropriate under the circumstances. The subject matter of this publication is not tied to any specific insurance product nor will adopting these policies and procedures ensure coverage under any insurance policy.