WHITEPAPER: HEALTHCARE

Moving Beyond the Dashboards

Analytics in Health Plan Operations

Operational
Command Center

Revenue Cycle Population Health

Management Management

Healthcare Solutions
for Health Plans

360 Degree CMS Reporting

Member View Mechanism
Integrated Self Serve
Big Data Infrastructure

Pre-built Integration to
Enterprise Systems

Datashop
WHITEPAPER: ANALYTICS IN HEALTH PLAN OPERATIONS

Introduction
Operations organizations at payers are struggling to answer some of these questions every month,
quarter or year:

Capacity of Mailroom and Capacity in Appeals &

Data Entry Centers Grievances
What capacity do we need in our Do we have enough capacity in
mailroom and data entry centers for open Appeals & Grievances based on the
enrollment? denial trends we are seeing?

Number of Call Center Agents Efficiency of Pre-pay

needed to answer calls
Do we have enough call center agents to
answer calls for a particular product next
week – have we considered all the claim
denials over the last one month?
Claims Audit
Are we doing efficient pre-pay claims
audit by considering error trends,
seasonality as well as provider
profiles?

Intelligent Operations Framework powered by smart analytics platform is the answer.

At most healthcare payers, analytics is the fiefdom of the actuaries. They slice and dice claims receipt
and payment data, demographic information to determine where the dollars are being spent and which
product is making the most money. Analysts in Finance departments of payers try to predict what the
next quarter or the quarter after will look like for Medical Loss Ratio but, Operations which provide all the
information for such analysis are laggards in usage of analytics to ensure they can prepare better for the
next week, month, quarter and beyond.

Operations organizations are stuck in historical dashboards, they review these at multiple levels within
their hierarchies for what has already taken place. The trouble is that dashboard information is not always
sufficient to prepare the operations organizations for the future, most of the time there is no predictive
modeling built into these dashboards.

For payers in the government sponsored healthcare space like Medicare Advantage plans, they need to
save every dollar possible to keep their ALR at around 10% and the best way to achieve it is by forecasting
expense trends so that they can react better. That’s where analytics plays a role in operations planning
and execution.

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Challenges facing Health Plan Operations

Let us first define which areas are included for the purposes of this whitepaper.
Operations comprises:

Mailroom Customer Service

Membership Accounting Appeals & Grievances
Provider Maintenance and Claims Compliance
Cost Containment

All of these operating areas have their own unique set of challenges that can be addressed
through the three of the four types of analytics:

Descriptive Analytics Diagnostic Analytics Predictive Analytics

What is happening? Why did it happen? What is likely to happen?

This table below illustrates what type of problems facing a department will benefit by
a particular flavor of analytics.

Department Business Problem / Use Case

Mailroom Cause of EOBs returned Diagnostic

Analytics
Claims Identify claims that need to be adjusted for Dual
Eligible benefits
Descriptive
Analytics
Compliance How is the claims department doing against CMS
measures

Cost Containment Alert Provider Relations on the effect of recovery

project on providers/groups and severity of their
reaction

Customer Service Markets or products with a higher volume of calls after Prescriptive
the EOBs are sent out Analytics

Appeals and Grievances Claims (POS and Procedure Codes) with the most
appeals, and how to forecast volume based on history

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Command Centers –
Enhancing Post-Facto Dashboards

Creating an Operations Data Network

For making effective operations decisions, managers rely on data flowing in from various sources. For
example, claims process would depend on data from mailroom, EDI clearinghouse, provider information
systems, claims adjudication system, pre-payment FWA audit systems, authorization systems, delegated
vendor claims payment systems, eligibility systems to name a few. Integrating these various data sources is
critical so as to free up talent to focus on operational decisions than data. It would enable departments to
spend more bandwidth thinking about “how can I take better care of our members and providers”.

Humans can never be replaced, however their work can always be augmented via smart machines. That
is the underlying philosophy behind Operations Data Network. It creates an environment where data and
technology can reduce manual intervention and setup automated data streams and pipelines, which can
then be rapidly utilized for decision making.

Process View of Operations

One of the key benefits of an Operations Data Network is that it enables a process view of the operations
which one can drill down to get further granularity.

Claims Flow Pipeline

All Products All States

Claims Mailroom Provider & Member Claims Claims Manual High Dollar FW
Resolution Auto-adjudication Resolution Review
EFFICIENCY

93% EFFICIENCY EFFICIENCY EFFICIENCY EFFICIENCY EF

OLDEST CLAIM IS 94% 96% 78% 86% 7

3 days old OLDEST CLAIM IS OLDEST CLAIM IS OLDEST CLAIM IS OLDEST CLAIM IS OL
(Oct 8, 2015)
3 days old 3 days old 15 day old 8 days old 1
view details (Oct 8, 2015) (Oct 3, 3015) (S
(Sep 26, 2015) (Oct 10, 2015)

view details view details view details view details vie

Claims EDI
Clearing House

EFFICIENCY

91%
OLDEST CLAIM IS

5 days old
(Oct 6, 2015)

view details

Figure 1: Process View of a Claims Pipeline

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This type of a process view can be setup with thresholds so that process health can be monitored visually
and managers need to intervene only when there are exceptions. In the example above, data is flowing into
this command center for this process from various sources, those data are then cleansed and business rules
applied.

Structuring

Classification

Cleaning

Figure 2: Data Flow from various sources to Command Center

Building Intelligent Command Center

Operations organizations at most payers have a wide array of dashboards that are created using historical
data – to provide actionable information for managers one needs to pipe in real-time information from the
disparate data sources referenced above. This is the Command Center approach.

In an analytics driven Command Center there would be department specific as well as cross department use
cases. Some examples of department specific use cases would be:

Straight through processing of enrollments (Membership Accounting)

Dual Eligible claims processing (Claims)
Call forecasting based on claims denial trend (Customer Service)

Trend for Calls Jul 23, 2015 – Oct 22, 2015 All Products All States 1m 2m 3m Custom

Estimated Calls Actual Calls

4k
Number of Calls

3k

2k

1k

0
Jul 23 - Aug 7 Aug 8 - Aug 22 Aug 23 - Sep 7 Sep 8 - Sep 22 Sep 23 - Oct 7 Oct 8 - Oct 22

Figure 3: Past Trend of Actual Calls vs. Estimated Calls

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 4k

Number of Calls
3k

2k

1k
WHITEPAPER: ANALYTICS IN HEALTH PLAN OPERATIONS
0
Jul 23 - Aug 7 Aug 8 - Aug 22 Aug 23 - Sep 7 Sep 8 - Sep 22 Sep 23 - Oct 7 Oct 8 - Oct 22

Estimated Calls October 14, 2015 – July 28, 2015

TOTAL ESTIMATED CALLS

10,000 - 15,000

By Plan By State By Professional Claim Type By Facility

Search product line.. Search state.. Search professional claim type.. Search hospitals..

PRODUCT ESTIMATED CALLS STATE ESTIMATED CALLS CLAIM TYPE ESTIMATED CALLS FACILITY ESTIMATED CALLS

Med Advantage Premier HMO 1,000 - 2,000 North Carolina 9,000 - 10,000 DME 1,000 - 2,000 Bayhealth Clinic 1,000 - 2,000

Med Advantage Gold PPO 1,000 - 2,000 Iowa 5,000 - 6,000 Lab 1,000 - 2,000 Mountains Hospital 1,000 - 2,000

Med Advantage Bronze POS 500 - 1,000 Mississippi 3,000 - 4,000 Ambulance 500 - 1,000 Trinity Medical Clinic 500 - 1,000

Premier HMO MAPD 0 - 500 South Dakota 2,000 - 3,000 PCP 0 - 500 Castle Hospital 0 - 500

Utah 1,000 - 2,000 Specialist 0 - 500 Overlook Center 0 - 500

Maryland 500 - 1,000 ASC 0 - 500 Green Medical Clinic 0 - 500

Figure 4: Estimated Calls by Plan, State, Facility and Claim Type

South Dakota 500 - 1,000 SNF 0 - 500 Morningside Clinic 0 - 500

Georgia 0-500 ESRD 0 - 500 Community Hospital 0 - 500

Some examples of cross-department use cases

Massachusetts 0-500 would be ER 0 - 500 Peace Forest Hospital 0 - 500

view more view more view more

• Credentialing process
• Provider contract implementation process – new and amendment
• Fee schedule update process

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Datashop Care for Payers –

Building Intelligent Operations Framework
The problem of integrating heterogeneous operational data sources across multiple platforms and
organizations has been one of the primary barriers to building an efficient operations analytics platform.
Operations data sources can vary from widely-used, standards-compliant products to custom data
formats particular to a platform, for example claims data can be in a completely different format from the
authorization data from a care management system. Datashop Care for Payers is an advanced data science
platform to address this problem with a highly interoperable architecture that hosts reusable, modular
connectors that – like the data sources they integrate – can be standards-based, product-based, or completely
customized. Hosting these connectors within this architecture allows Datashop Care to provide unified
administration, configuration, and monitoring tools for an organization’s various systems and interfaces.
With these capabilities, all within a unified architecture, Datashop Care can effectively address the range of
integration challenges with maximum reusability and manageability.

Realtime
Analytics Predictive Distribution of
Analytics
Claims Data Resources

Optimum use of
Resources
Member Data

Pricing

CRM Data
Minimum
Business Risk

A&G Data Inventory

Management
Datashop Care

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Using Machine learning, Natural Language Processing and proprietary automation algorithms, Datashop Care
offers a suite of data management and integration engines to build a Rapid Clinical Information Network. It is
also integrated with project management features to monitor the data pipeline and triage issues with role-
based access.

Some of the major features that Datashop Care offers include:

Intra-Organizational Operational Information Network

Data Extraction Connectors
360 degree member view
CMS Reporting Mechanism
Revenue Cycle Management
Operational Command Center
Population Health Management
Monitoring Dashboards
Pipeline Management
Discovery Surveys
Analytics Engine (Predictive, Descriptive, Prescriptive)
Reporting Engine

EMRs Claims External Data

R Packages

Python Packages
Analytical
Data Connector Layer Engine Predictive Models

Descriptive Reporting
Structuring

Datashop Query
Classification Language

Data warehouse - Web dashboard

Cleaning Hadoop
Cluster Population Health Metrics

Profiles - Patient History, Potencial Risk

Data Pipeline Management Visualization
and Monitoring Engine Length of Stay, Readmission Likelihood

Figure 5: Architecture Diagram of Datashop Care

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ABOUT INNOVACCER

At Innovaccer, we create products that transform the way

organizations use data. Our products and services are deployed
at Hospitals, Accountable Care Organizations (ACO), Health
Information Exchange (HIE), critical government, commercial, and
non-profit institutions around the world to solve sophisticated and
world changing problems. Simply put, we accelerate innovation
through the power of data.

To know more about how Datashop Care can help you build an
Intelligent Operations Framework, advantages, timelines and other
features – please contact us at:

info@innovaccer.com

Innovaccer, Inc.
Stanford Financial Square, 2600 El Camino Real, Suite 415
Palo Alto, CA 94306, United States
(O) +1 714 729 4038

© Innovaccer Inc 2015

Innovaccer, Innovaccer Inc, and Innovaccer Datashop are trademarks of
Innovaccer Inc. All other company and product names may be trademarks
with which they are associated with. Datashop Care is a proprietary
technology and Intellectual Property of Innovaccer.

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