Healthcare

Featured Solutions

External data rating modifier for a payer

External data rating modifier for a payer

With an innovative analytical framework applied on external data, payers can enhance the performance of existing rating modifiers to inform additional risk. Health insurers can leverage new signals from consumer data to predict claims experience to deliver an improved risk assessment process. These new signals include factors indicating buying behavior patterns, socio economic and financial statuses and health interests.

The enhanced rating modifier can help payers create an R-squared lift of up to 15%.

This lift is over and above claims experience typically informed by internal risk factors that payers already assess—such as age, gender, and location.

A few external indicators of additional risk informed by claims experience can include data on economic stability, usage of mobile phones, prime time television usage, smoking, community engagements, derogatory records, and dwelling status.

Claims anomaly detection for a payer

Claims anomaly detection for a payer

It’s time for payers to experience a better way to identify anomalous claims. The common process to identify anomalies is business-rules-driven, manual intensive, applied in a post-pay scenario and focuses mainly on known patterns, thus solving the problem partially.

Applying advanced analytics and looking for opportunities beyond overpaid dollars, such as better utilization management, plan design changes and network optimization, helps detect hundreds of unknown anomalies.

Payers can use the new analytical framework to drive up to $50M additional impact within the first year of operationalization — by increasingly focusing on unknown anomalies.

Get better results by:

  • Applying predictive analytics and AI to better prioritize claims for SIU review
  • Automating the entire anomaly identification process
  • Creating a visual solution suite to help identify anomalies, track alerts, and measure the impact of interventions
  • Delivering significant impact in both post-pay and pre-pay scenarios

 

The significant ROI in initial year/s enables payers to self-fund a suite of more advanced AI-driven scalable solutions to keep identifying and tracking anomalies, and improving recoveries from the flagged claims.

Case Studies

  • Reduce high costs of care associated with avoidable ER visits
    3 min. read

    Reduce high costs of care associated with avoidable ER visits

    A payer identifies opportunities to redirect avoidable ER visits, saving $10MM in cost reductions

    The Big Picture The high cost of maintenance and limited availability of Emergency Rooms (ER) facilities are under intense scrutiny by payers, the government, providers and employers. According to the Centers for...

  • Improve collectability of the self-pay portion of medical expenses
    3 min. read

    Improve collectability of the self-pay portion of medical expenses

    Analytics helps a leading provider network identify patient segments to collect $20MM from unpaid invoices

    The Big Picture Escalating healthcare costs have forced employees with employer-provided insurance to bear a higher portion of self-payment costs such as co-pay, coinsurance, deductible and out-of-pocket expenses....

  • Pharmaceutical uses behavioral science informed design to reduce prescription attrition
    3 min. read

    Pharmaceutical uses behavioral science informed design to reduce prescription attrition

    A patch-based dopamine agonist used to treat Parkinson’s Disease was facing a steep attrition rate of 50%. A new behavioral understanding led to significant changes in treatment outcomes.

    The Big Picture As a manufacturer of a patch-based dopamine agonist used to treat Parkinson’s Disease, a major global pharmaceutical was facing a steep attrition rate of 50%, post two months of prescription uptake....

  • Develop prediction framework to address high attrition
    3 min. read

    Develop prediction framework to address high attrition

    A pharmacy distributor identifies $45MM opportunity to boost customer retention by predicting attrition

    The Big Picture Wholesale drug distributors have experienced strong competition and consolidation leaving only a few surviving entities to service most of the US market. A leading distributor of drugs to long-term care...

  • Improve medication adherence to lower health costs and improve patient outcomes
    2 min. read

    Improve medication adherence to lower health costs and improve patient outcomes

    Better problem solving and machine-learning helps healthcare payer save $5MM from reducing medication non-adherence

    The Big Picture Non-adherence of medication is one of the most critical problems when treating patients with chronic conditions. Patients who do not follow the prescribed drug regimen are more likely to suffer poor...

  • Leverage external data to improve pricing and underwriting decisions
    2 min. read

    Leverage external data to improve pricing and underwriting decisions

    A payer better predicts claims experience with external data, supplemental to internal claims data.

    The Big Picture A leading health insurer believed it could better predict claims experiences using external data, as supplement to internal claims data. The organization wanted to leverage the predicted claims...

  • Improve claims anomaly identification and tracking
    3 min. read

    Improve claims anomaly identification and tracking

    A payer identifies $5M+ in potential savings in first year of powering claims anomaly identification with analytics

    The Big Picture A top 5 US payer wanted to improve its ability to identify and track claims anomalies. Its existing process was business rules-driven, significantly manual, applied only in a post pay scenario and lacked...

  • Biotech uses data to unlock $100M opportunity to improve revenue.
    3 min. read

    Biotech firm uses data to unlock $100M opportunity to improve revenue.

    Advanced analytics predicts decline in drug prescriptions to engage physicians and drive sales

    The Big Picture: A leading pharmaceutical company was facing a decline in the sales volume of its flagship drug, which usually accounts for over $5 Billion of its annual sales. Less than 30 percent of physicians...

  • Top 5 US health payer identifies $45M in overpaid claims
    3 min. read

    Top 5 US health payer identifies $45M in overpaid claims

    Unsupervised learning methods helped recover claims payments and contain costs from fraud, waste, and abuse

    The Big Picture: The US healthcare system loses more than $200 billion every year in fraud, waste, and abuse-nearly 10 percent of annual healthcare spending. The Government Accountability Office (GAO) has deemed...

Our People

  • Pooja Rao

    Pooja Rao

    Principal Data Scientist, Qure.ai
    • Physician-scientist
    • Machine learning expertise across healthcare and life sciences
    • Bioinformatics and genomics
  • Sankar Narayanan (SN)

    Sankar Narayanan (SN)

    Chief Practice Officer
    • AI led business and functional transformation
    • Hi-Tech, Media & Broadcasting, Industrial engineering
    • Sales & Marketing Effectiveness, Customer experience, Digital Strategy