Health Insurance

Early detection of improper payments. Predictive, accurate claims decisions. And hundreds of millions in savings. We can help you get ROI from your payment integrity efforts with solutions that address:

• Fraud and improper payments (waste and abuse). Detect improper payments before the money goes out the door, and get potential savings of hundreds of millions of dollars. Take an enterprise approach to detecting and preventing fraud, waste and abuse with a hybrid analytics solution.
• Eligibility fraud. Determine eligibility in Medicaid, MCOs and state employee and traditional health plans to avoid unwarranted costs – using sophisticated analytical tools and a variety of data sources.
• Enterprise case management. Manage investigation workflows, attach commentary and record financial information, such as exposures and losses using a holistic, structured case management environment.
  

Spot hidden connections, patterns and anomalies – possibly years ahead of traditional methods. Uncover more fraud, waste and abuse than ever before using four key analytic detection methods instead of just one. And go beyond traditional, rules-based fraud, waste and abuse detection to make predictive, accurate claims decisions before money goes out the door. Only SAS enables you to:

• Take a unique, hybrid approach to payment integrity. A hybrid analytics approach combines business rules, anomaly detection, predictive modeling and network analytics to find more fraud, waste and abuse than any single method alone.
  
• Quickly uncover organized fraud rings. Identify targets that are likely to lead to emerging or migrating schemes by building fraud propensity scores using predictive modeling techniques on new events and on prior cases of known fraud.
  
• Expose previously hidden relationships among entities. Using social network analysis, you can see connections between discrete episodes of fraud, waste and abuse with a unique visualization interface.
  
• Improve investigator efficiency. Using prioritization methods, the system automatically routes potentially fraudulent claims to the right resource based on type, skill set, experience and workload.
  

A comprehensive view of a member’s health. Insight into costs and conditions by episode of care. And customized patient interventions and communications. We deliver software that helps you improve operations and deliver patient-centric services through:

• Value-based care and payment models. Better predict costs of care and go beyond individual episodes to get broader insight into a member's health. 
• Risk adjustment maximization. Uncover undiagnosed and underdiagnosed conditions, and use the insights gained to document patient conditions for Medicare Advantage plans and other reimbursement opportunities. 
• Membership portfolio optimization. Provide members with a more personalized health insurance experience and better service while managing health care costs.
  

Predict costs of care down to individual episodes. Understand your risk profile better than ever before. And manage expenses associated with providing care. SAS enables you to:

• Provide incentives for improved outcomes, reduced costs and other aspects of patient care. Armed with episode-based care information, you can better collaborate and coordinate care across providers for better outcomes at lower costs.
• Maximize and protect your CMS risk-adjusted revenue streams. Focus on targeted populations with the greatest potential for revenue lift. Identify audit-worthy conditions. Monitor the flow of submissions. And ultimately get the greatest reimbursement for your risk adjustment maximization initiatives.
• Balance your membership portfolio. Using data integration and advanced analytics, you can identify high- and low-risk members, build detailed segmentation models and better align products, programs, resources and services to manage costs.
  

Lower costs per sale. Better marketing performance through better targeting. And an optimized portfolio of membership. SAS offers innovative, modular solutions that address:

• Customer acquisition. Turn customer insight into competitive advantage, and get more campaigns out the door faster.
• Customer retention. Better understand and predict customer behavior so you can develop more effective marketing strategies designed to retain your most profitable customers.
• Marketing optimization. Gain critical knowledge about factors that influence the success – or failure – of your marketing campaigns, such as adding a new channel, reducing a budget or altering a member contact policy.
• Cross-sell/up-sell. Get valuable customer insight to drive smarter decision making by understanding members’ health care buying habits and behaviors, response propensities, and profitability and value.
• Health intervention. Dive deeper into health care data to identify trends and predict risk. Then tailor offerings and optimize interventions to meet health care needs and improve outcomes.
  

Shift your business model from wholesale to retail. Acquire, retain, service and manage the health of individual consumers. And identify and target your ideal membership within predefined MLR corridors. With SAS, you can:

• Get a complete picture of each member relationship. Create a single view of a member using comprehensive data management capabilities to consolidate all relevant data – from policies, claims, billing, etc. – in one place regardless of source, then cleanse and transform the data so it's ready for analysis.
• Better understand – and predict – member behavior.  Build and deploy baseline consumer models designed to predict critical member behavior and financial outcomes. Then ensure their ongoing validity by monitoring and testing model performance, and updating them as needed.
• Manage your marketing organization's performance. Streamline and automate consumer engagement and marketing. Test performance by generating, viewing and sharing the metrics that matter most. And get the best possible financial and membership returns from your consumer engagement initiatives and programs.

A deeper understanding of member and population health. More relevant, effective member communications. And improved quality of care, along with reduced costs. We provide the most effective solutions for addressing:

• Health and condition management. Uncover hidden health trends. Identify the most effective treatments. And assure the best possible care to improve outcomes.
• Readmissions. Identify and predict which members are at high risk of readmission. And choose the most cost-effective and appropriate member-specific interventions.
  

Thoroughly understand the health characteristics of your member population. Identify those at high risk for disease and those most likely to respond to treatment programs. And proactively manage readmissions. With SAS, you can:

• Generate real-time readmission risk scores. Capture and analyze patient data on demand, and pool cross-system data to see patterns needing optimization.
• Gain a 360-degree view of your health care population. Use analytical models to understand behavioral attributes of entire population segments. Even identify high-cost segments so you can manage problem areas proactively.
• Measure the overall performance of treatment plans. Develop a consolidated view of treatment plan compliance, and report on performance at an aggregated or more detailed view.
• Significantly improve the probability of member compliance. Automate a member communication and response system that lets the plan interact with members over their preferred channel at the time and frequency required.
  

Access to as broad a set of member and claims data as possible. Deeper insights on all aspects of your business. And the ability to work with providers on collaborative arrangements designed to deliver improved cross-continuum care. We can help you manage your data and build a solid health analytics foundation with solutions that cover:

• Data integration. Ensure easy access to all relevant claims and operational data, regardless of system or format.
• Data quality. Improve your data’s lifespan and ensure trustworthy analyses by making sure your data is consistent, reliable and always up-to-date.
• Master data management. Develop a master data management program that lets you govern consistent data, create a single unified view of your data and implement more effective processes.
• Data visualization. Look at your claims data in a whole new way by visually exploring data to uncover hidden patterns and connections that can lead to new insights.
• High-performance analytics. Get insights faster than ever before by processing analytical models in a fraction of the time it used to take. And make strategic, time-sensitive decisions with confidence.

Transform volumes of claims, clinical and other types of data from across systems and platforms into useful information. Gain new market insights. And adapt to a more consumer-centered health insurance market. Only SAS offers the breadth of capabilities to bring your analytic prowess to the highest level, so you can:

• Break down silos for a consistent view of data. Rapidly connect with common data sources through standards-based interfaces. And take advantage of a flexible, scalable data integration platform that lets you cost-effectively integrate your current and future data.
• Use all relevant data in your analyses. You can use all your structured and unstructured data – not just a subset – to understand member and book of business risk or successfully manage to a minimum or maximum MLR.
• Implement a scalable IT infrastructure for analytics. Take advantage of in-memory processing to test new ideas and evaluate more scenarios. All without constraints.