Highmark maximizes Medicare revenues with SAS® Enterprise Miner
Health insurance companies that participate in the federal Medicare Advantage program are reimbursed based on the level of illness in the population they cover, which is measured using diagnosis codes. But what happens when a patient has an illness that a hospital or physician’s office doesn’t code properly? Or a member does not seek services for that condition in a particular year? Insurers risk losing thousands of dollars per case. With SAS Enterprise Miner, Highmark dramatically reduces that risk.
"For example, if we find that someone looks like they have Parkinson’s disease or chronic obstructive pulmonary disease, but the patient’s claims are missing the specific diagnosis code tied to the disorder, that will potentially cost us a lot of money," explains Brian Day, Highmark's Director of Advanced Analytics. "Using SAS, we can identify which cases have the highest probability of reimbursement potential. Our revenue management area would then submit a change and receive proper reimbursement."
Although Highmark could theoretically review every chart for missed diagnoses, it is important to effectively whittle down the number of cases that might require resubmission because the actual process is costly and time-consuming. “With SAS we don’t have to do as many chart reviews and that improves the bottom line,’’ Day says. “This program identifies millions of dollars in previously undetected medical risk each year.”
Here's how it works: The decision trees build predictive models that comb through reimbursement data looking for treatments and prescriptions that suggest a population of patients that have an undiagnosed condition, such as diabetes. In the diabetes example, some patients might have been diagnosed with diabetes in the past, but for unknown reasons their diagnosis is no longer on their records - even though they are insulin dependent or have other markers of the disease. By summing up the parts of the 27 disease hierarchy trees - each with hundreds of variables - patients receive a comprehensive, severity-weighted “possible diagnosis gap” score.
“We can be strategic in the way we identify underlying conditions,’’ Day says.
“With the capabilities we have from SAS, there is no reason to go with an outside vendor,’’ Day says. News about the work in Day’s group has spread. Highmark’s division in charge of its Medicare Advantage program now wants to move its condition management process internally, using SAS as a base for the analytics.
With SAS®, Highmark can also:
Develop sophisticated data mining skills easily. Day’s group recently transitioned to SAS®9, a process that went very smoothly. “The SAS experts have been nothing less than super. And the training helps my staff use SAS immediately.” Day himself had not data mined prior to using SAS, yet found it easy to pick up. “The gist of the process was very explainable. It’s just so nice and straightforward to work with.
“SAS helps us do some very sophisticated processes. If we didn’t have SAS we couldn’t come up with some of the answers we’ve gotten.’’
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Brian Day, Director of Advanced Analytics
Find un- or misdiagnosed patients with illnesses that qualify for higher Medicare reimbursements
SAS Enterprise Miner
The insurer estimates it saves millions by finding patients with one of 27 illnesses that qualify for higher Medicare reimbursements
“SAS helps us do some very sophisticated work. If we didn’t have SAS we couldn’t come up with some of the answers we’ve gotten.”
Director of Advanced Analytics