Health Analytics

Analytics is the buzz word in the current market scenario. Almost all sectors use analytics in some form or the other and Healthcare industry is no different.  In fact, Healthcare Analytics is an evolving field in health care business. With Healthcare reforms In US becoming more stringent, Healthcare providers are looking up to Analytics to drive better fact-based decisions. Basically, making use of extensive data by statistical and quantitative techniques for modeling and analysis purpose is Analytics. Health Technolgy’s Analytics services provide clients with optimized solutions for achieving their goals within the healthcare and other horizontal industries. We approach each scenario with a methodical and well defined approach and thus assist clients to enhance their operational metrics through a multitude of enhancements. This is accomplished by using the best subject matter experts, analytic tools and database programmer to support our client’s decision making process. Some of our major services in this line of specialization are:


Claim Analysis

Our team mainly focuses upon member utilization, providers, pharmacies and protected classes and use consultative approach to analyze various trends in the claims data, determining levels of reasonable and necessary charges for all PBM claims. The claims analytic function primarily deals with prescription claims data and focuses on utilizing member, provider, pharmacy, protected class etc. Our analysts provide various standardized and customized reports on drug utilization, in line with the clients’ requirements.

Our team of experienced claims analyst’s deal with accepted and rejected claims data as received from a Plan sponsor’s PBM system. Some of the key services in this line of claim analysis are:

PDE Reconciliation

Our PDE reconciliation process comprises several integrated, inter-related steps that encompass PDE error analysis, creation of action plan for PDE correction as well as resubmission and finally, flawless reconciliation of PDE data with that of the paid claims and CMS’s accepted PDE records. Our expertise in PDE reconciliation and analytics provides an exceptionally high rate (>99.5%) of PDE acceptance. Some of the general services in PDE reconciliations are:

  • PDE error resolution approach ensuring prompt and correct resolution of PDE errors thereby increasing PDE acceptance rate
  • The PDE analysis & resolution cycle starts with upload of PDE data into PDE data warehouse
  • Analysis of PDE errors reported by CMS
  • Identification and classification of errors based on eligibility and non-eligibility issues
  • PDE team identifies PDE records with “INF” warning messages and associated codes, and informs the enrollment team for follow up action to avoid future rejections
  • Preparation of project plan for correction and resubmission
  • PDE analysis and resolution team works closely with the enrollment team as well as the PBM
  • Follow up with PBM for reprocessing / regenerating the corrected PDE records for both eligibility and non-eligibility issues
  • Reconciliation of new PDE records with the rejected records to identify missing records
  • Submission  of new PDE file to CMS and continue the cycle
  • Regular status update of PDE correction projects  provided to all the stakeholders
CTM Root Cause Analysis

Our proprietary CTM analytic solution known as CTMPro focuses on the effective resolution of CTM complaints and also provides insight into the reasons, underlying these complaints. This significantly helps the plan proactively improve their services and offerings, including the Plan Benefit Design, copayment levels, out-of-network options, and changes to formularies. We analyze CTM complaints with reference to paid and rejected claims, member eligibility data, member level rules, and plan specific formularies to identify root causes behind CTM complaints, thereby accelerating and streamlining the entire resolution process and thus reducing future CTMs.

CTMPro helps in the analysis of the following:
  • Root cause analysis of complaints registered through CMS’ CTM system
  • Denial of medication
  • Deficiency in services rendered
  • Deficiency in service offerings
  • Analysis of rejected claims to find correlation between CTM lodged and claims rejected
  • Protected class drug rejections
  • Formulary coverage and deficiency
  • Non-compliant rejections
  • Identification of patterns and trends of CTM complaints
  • Generate indicators on nature of CTM complaints
  • Identification of prospective CTM complaints
  • Mine related information for resolving CTM complaints
  • Work flow based case resolution system
  • Case worker to resolve CTM complaints
CMS Payment Reconciliation

Our CMS Payment Reconciliation comprises tech-assisted, high-end info-crossing system that seamlessly reconciles monthly CMS membership and payment data to Plan membership data. We provide an accurate system-calculated, plan-expected payment in which enrollment slip-ups as well as data and payment discrepancies are automatically factored.

Risk Score Adjustment

Our Risk Score Adjustment process consists of dedicated personnel who, based on several CMS compliant parameters, allocate a risk score to the beneficiary. This ensures prevention of overpayments to plans that have large numbers of healthy beneficiaries and underpayments to those with relatively higher numbers of sick beneficiaries.

Chart Review & Coding

The Chart Review and Coding services offer unbiased insights into professionally reviewed, case-specific health care information, underlining the medical aspects of a patient’s history, treatment and care. We help our clients coordinate and systematize necessary information from medical charts, which is eventually abridged or highlighted for further considerations or catalogued for necessary identification.

Data Warehouse Design

Our exclusive Data Warehouse design models encompass staging, access & integration of data for further data mining, online analytical processing, market research as well as decision support. We ensure relevancy and avoid inconsistency, while maintaining low overall expenditure.

Data Modeling

We offer comprehensive, enterprise data modeling services to our clients to efficiently meet their versatile business needs. Our solutions range from conceptualizing data models to their physical execution. Our customized model faultlessly maps the business requirements of clients, whereas our logical data model effectively defines their database structures, providing an extensive portfolio of insightful business solutions.

Our experienced data modelers/statistician ensures that the conceptual data model is perfectly in sync with the physical implementation of our logical model through seamless physical data optimization model.

Decision Support Implementation Disease Management

We provide clients with a unified reporting, analytical, and monitoring platform that forms the core of any Decision Support System. Our interactive, integrated and scalable platform effortlessly supports an increasing concurrent user base, enabling clients to rapidly develop and deploy projects.

Financial Analysis & Payment Reconciliation

Financial analysis, in any Part D organization, demands unparalleled knowledge of CMS payment methodologies, Plan benefit design, administered dollars for claims and other associated operational costs. Plans receive a set of management reports from Payment Reconciliation System (PRS) of CMS, which allow them to validate the beneficiary level inputs from DDPS and MARX. All plans must perform their own level of reconciliation in sync with the CMS reconciliation to avoid any under/over payments. Our experienced team accurately predicts the CMS Payment Reconciliation, using PDE files and other beneficiary level inputs from DDPS and MARX.  We seamlessly validate a Part D Plan sponsor's internal reconciliation with that of PRS, and appeal, if required.

Drug Utilization

Our analysts provide various standardized and customized reports on drug utilization, in line with the clients’ requirements. Some of our key reports reflect on - average beneficiary utilization, based on Rx#, TDC, average cost per Rx for brand & generic drugs, brand vs. generic utilization, therapeutic class wise distribution etc.

Fraud and Abuse Analysis

Fraud and abuse are very common to Insurance and health-care system. Fraud involves intentional deception or misrepresentation of information which is intended to result in unauthorized monetary benefits whereas abuse involves charging for services which are not medically necessary or are unfairly priced. Our team can help in the detecting the following:

 

425 Washington Blvd., Jersey City,
New Jersey 07302, USA

Phone: +1 201.258.4704 / 201.258.4704
Fax: +1 201.604.3480