Analytical Insights Critical for Smart Business Decisions

For health plans with limited resources, cost pressures continue to weigh heavy. Outdated technology and siloed systems can adversely impact operational efficiency, create significant processing challenges, drain productivity, and ultimately impact the bottom line.

Health plans require analytical insight into the business in order to identify trends and make well-informed decisions. However, the data is often on separate legacy systems with varying data structures, making it difficult to merge data for month-over-month, year-over-year analytics across the portfolio.

The ability to provide robust, comprehensive data to customers and trading partners can be an enormous challenge for health plans.

For example, I worked with a regional plan in the Mid-West with Commercial, Individual, Medicare Advantage, and Medicaid lines of business.

The plan wanted a way to track claims applied to member deductible (Out-of-Pocket), see the specific authorization used when the claim processed, and calculate how many visits a member has used on a limited service such as physical therapy without counting line-by-line. They also wanted a way to easily share that information as well as simplified balance due, credit amounts, and other billing details with their members.

The plan’s legacy platform did not offer a reporting solution with real-time operational insights. Instead, their reports included old data that was useless when trying to provide meaningful information. Not all information in the system was effective date-driven, and some critical data was only point in time, resulting in financial errors and incorrectly processed claims.

Without complete, robust, and accurate data, all in one system, errors will continue. Health plans need a reliable system that is easy to maintain and provides operational data for reporting and analytical dashboards to make critical business decisions.

To successfully compete in today’s market, health plans need next-generation technology and access to real-time analytics that provide insights that enable transparency inside and outside their organizations.

About the Author

David Nesbitt

David Nesbitt, Vice President, Sales Operations

David is a senior executive responsible for sales operations across the HealthEdge solution suite. In his current role, he supports all HealthEdge sales activities including partner relationships. David has more than 25 years of healthcare payer experience and brings a broad background spanning software development, product management, professional services delivery and sales. He has been with HealthEdge for more than 13 years. During this time, David has served as Product Manager designing HealthRules Payor functionality as well as Senior Director of Business Services managing the business consultants and education services in Professional Services. Prior to his tenure at HealthEdge, David held product management and delivery roles at NaviNet and Verisk Analytics. His early healthcare experience was in the role of software development at Healthsource/CIGNA. 

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With HealthRules®, health plans can meet the rapidly changing healthcare industry’s demands with full confidence. HealthRules can combine with analytics to provide insights that improve patient outcomes, lower costs, and enable transparency inside and outside the health plan. Download the data sheet to learn more.

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