CMCRC has developed technology solutions to serve as the backbone infrastructure for local, regional and global markets. The focus of the CMCRC is on developing solutions for insurance and healthcare markets to support both policy and operational decision making and to enable surveillance of markets to assure their integrity and efficiency, to deliver quality care and optimal patient outcomes.
The research and technology development of the CMCRC seeks to addresses the interaction between technology and key market elements –providers, hospitals, funders and patients in the delivery of: claims assessment and surveillance, costing, contracting, patient administration and billing. The CMCRC is currently working on expanding its solution suite in claims assessment as has commercialised research in claims surveillance.
The schematic below illustrates the scope and coverage of the health insurance leakage detection and analytics platforms.
HIBIS is a fully featured solution that provides the functionality required by insurers for effective health claims analysis and in particular the automated identification and management of claims leakage (fraud, abuse, waste and errors) across the full spectrum of hospital/medical and ancillary claims.
- Receipt of claims and HCP (discharge) data in real-time or post-processing mode. Data exchange interfaces are in place for a number of major claims processing solutions.
- Processing of claims through the HIBIS analytics engine with the resultant alerts (firings) being stored together with the claim lines in the HIBIS Central Database. Where a real-time interface has been implemented alerts are also passed back to the fund’s core transactional system.
- Analysis of claim alerts via the HIBIS Alert Explorer which provides full access to claims and related alerts (firings) information through a web-browser interface. The Alert Explorer provides the context required by a claims analyst/inspector to determine what action to take in relation to an alert. Multiple views are provided based around e.g. claims, providers, members or a combination of these. The Alert Explorer provides an extensive drill-down capability and allows for the recording of actions taken (e.g. claim rejected, alert overridden) and results achieved (e.g. refund received).
- Workflow to enable analysts and managers to update and keep track of claim alerts as they progress from investigation to recovery or closure.
- Generation of reports based on parameters of time, provider, member, rule, value, etc
- Generation of data exports (in e.g. csv format) from reports.
HIBIS features the functionality required by insurers to ensure effective health claims analysis and management.
I+PLUS Analytics Platform
I+PLUS is an advanced analytical solution that provides:
- Identification of outlier admissions in which the costs (hospital, doctor, prosthetics) and length of stay in hospital are greater than the forecast produced via one of the thousands of models embedded in the solution.
- Assessment of provider’s comparative performance in relation to the cost of treatment, length of stay, and incidence of adverse events.
- Analysis of actual and optimal payment models e.g. DRG case payments and per diem.
- Claims leakage detection (from a different perspective to the HIBIS solution).
I+PLUS is built on a foundation that applies claims-scoring and predictive modelling to each health claim. Analysis and reporting is then available at an individual admission level as well as at multiple aggregated level above that – e.g. procedure type, provider and member.
I+PLUS brings together CMCRC’s experience in developing and deploying claims-scoring and predictive modelling solutions into Australia’s largest workers’ compensation insurer, with its experience in developing and deploying the HIBIS application into many health insurers.
I+PLUS’ predictive models are developed using advanced statistical techniques that run through large volumes (e.g. multiple years) of historical claims and hospital discharge data to identify the key features (e.g. primary treatment and diagnosis codes, age, co-morbidities, nature of prosthetics, public/private hospital) and then model the expected costs and lengths of stay for like types of procedures/treatments. Each claim is then compared with its forecast value and the differences are identified and analysed.
I+PLUS follows the treatment classification structure used in the Medicare Benefits Schedule with models developed at the most appropriate level (node) in the hierarchy (e.g. Surgical Operations >> Orthopaedic >> Single Knee Replacement). At each node, models are created to predict: hospital charges, prostheses charges, medical charges and length of stay.
See more at: http://www.loricahealth.com