
Health Insurance
全面应对大数据挑战


Stop improper payments in their tracks. Before claims are paid.
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.
Recommended Resources
Early detection of agent gaming, customer gaming and the potential for future claims fraud.

Get the facts. Know your risk. And build a balanced member and payment portfolio.
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.
Recommended Resources

Identify the right mix of members. Then get, manage and keep them.
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.
The high performance of SAS Grid Manager pulled our scientists out of the dark.
Recommended Resources

Predict risk. Optimize interventions. And improve outcomes.
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.
Recommended Resources

Better member and cost insights. And success in a changing market.
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.
The high performance of SAS Grid Manager pulled our scientists out of the dark.
Recommended Resources

适时停止不当支付,在支付索赔之前
不当支付的早期检测。基于准确预测的理赔决策。获得数以亿计的成本节约。该解决方案帮助您从支付完整性中获取投资回报,解决下列问题:
- 欺诈与不当支付(浪费和滥用) 在支付之前进行不当支付检测,可以潜在节省亿万美元。采用企业级混合分析解决方案,检测和预防欺诈、浪费和滥用。
- 资格欺诈 使用全面的分析工具和多种数据源,确定客户是否具有医疗补助、医疗组织、政府职员和传统医疗保健计划中的资格,避免不必要的费用。
- 企业级案件管理 管理调查工作流程,附加备注和记录财务信息。例如在整体的结构化案件管理环境下,管理风险和损失。
很可能比传统方法提前几年的时间,发现隐藏的联系、模式和异常。利用四大主要检测方法而非单一方法,揭露比以前更多的欺诈、浪费和滥用。超越传统基于规则的欺诈、浪费和滥用侦测方法,最大的不同在于,在赔付之前做出准确预测的理赔决策。只有SAS让您能够:
- 采取独特的混合型方法来实现赔付完整性 混合型分析方法结合了业务规则、异常侦测、预测建模和网络分析等技术,相比于采用单一方法,能够发现更多的欺诈、浪费和滥用。
- 快速发现有组织的欺诈团伙 通过对新的活动或已知的欺诈活动预测建模,生成欺诈倾向评分,识别潜在的新兴欺诈模式或迁移模式。
- 使之前隐藏的实体关系显露出来 使用社交网络分析,您能够通过一个专门的可视化界面,看到在欺诈、浪费和滥用等分散病历之间的联系。
- 提高调查员的工作效率 进行优先级排序,系统可以将潜在的欺诈索赔,基于类型、技能、经验和工作量,分配给最适合的资源。
新泽西的Blue Cross Blue Shield
SAS帮助我们在90天内安装实施了坚实的医疗保健欺诈检测软件。这套软件已经开始帮助我们检测收到的药品索赔中的问题。SAS的团队完全理解并满足了我们的需求,并且和我们的团队一起工作得相当愉快。
— 信息、商业智能和数据管理部主任 Mike Occhipinti

认清事实,了解您的风险,建立一个平衡的会员和赔付组合
关于会员健康的全景视图,关于医疗服务中成本和约束条件的洞察,量身定制的病患干预和沟通。我们的软件帮助您改善运营,并为您提供如下以客户为中心的服务:
- 价值关怀和赔付模型 更好的预测医疗服务成本,不仅仅是简单的病例,而是关于会员健康更深入的洞察。
- 风险调优最大化 发现未曾诊断出的和正待确诊的疾病,利用所获取的洞察,对病人病情形成文档,用于医疗补助计划和相关报销。
- 会员组合优化 为会员提供更加个性化的医疗保险体验,在管理医疗保健成本的同时提供更好的服务。
预测个体病患的医疗服务成本,比以前更好地了解您的风险利润,管理医疗服务所产生的费用。SAS让您能够:
- 提供激励措施来改善预后,降低成本和其它病人护理等方面的费用 基于病历的医疗服务信息让您更好地协调医疗服务提供者,以较低的成本获得更好的预后。
- 最大化保护您的CMS风险调整后的营收 重点放在能够最大提升收入的目标人群上。确定审计价值约束。监控提交流程。让风险调整最大化举措获得最大回报。
- 平衡您的会员组合 应用数据整合和先进分析技术,发现高风险和低风险的会员,建立详细的细分模型,调整产品、项目、资源和服务,进行更好的成本管理。

识别会员的正确组合,获取、管理和留住他们
降低销售成本。精准锁定带来更好的营销绩效。优化的会员组合。SAS提供创新的模块化解决方案,帮助您:
- 获取客户 将客户洞察转化为竞争优势,更快设计更多可执行的营销活动。
- 客户保持 更好地了解预测客户行为,开发更有效的营销策略方案,保持最有价值的客户。
- 营销优化 了解导致营销活动成功或失败的关键因素,如增加新的渠道、降低预算或改变会员沟通策略。
- 交叉销售/提升销售 获取有价值的客户洞察,通过了解会员的医疗保健购买习惯和行为、响应倾向、利润贡献和价值,做出更明智的决策。
- 健康干预 深入挖掘医疗保健数据以识别趋势和预测风险。然后提供量身打造的服务和优化的干预,满足医疗保健需求和改善预后。
将您的业务模式从批发向零售转移。获取、保留个体消费者并为他们提供健康服务和管理。在预定义的MLR内识别和锁定您的理想会员。采用SAS软件,您可以:
- 获得关于每个会员关系的完整视图 使用全面的数据管理功能整合所有相关数据,创建会员的统一视图。这些数据包括保单、索赔、帐单等等,无论数据源在何处,都能进行统一整合,进行数据清洗和转换,为分析做好准备。
- 更好地了解和预测会员行为 建立和部署消费者基准模型,预测重要的会员行为和财务产出。通过监控和测试模型性能并适时更新,确保模型的持续有效性。
- 管理营销部门的绩效 简化和自动化消费者参与和营销。通过生成、查看和分享重要的指标来检验绩效。从消费者营销计划与营销活动中获取最佳的财务和会员收益。

预测风险,优化干预,改善预后
更深入地了解会员和人口健康。更有效更相关的会员沟通。改善医疗服务质量同时降低成本。 我们提供最行之有效的解决方案,解决下列问题:
- 健康管理 发现潜在的健康趋势。发现最有效的治疗方法。确保最可能能改善预后的医疗服务。
- 再次入院 识别和预测哪些会员存在较高的再入院风险。选择最经济有效最适用于会员的干预。
彻底了解会员人群的健康特征。发现那些有着患病高风险的会员,和那些最有可能对治疗项目响应的会员。前瞻性管理再入院比例。采用SAS软件,您可以:
- 实时生成再入院风险评分 按需捕捉和分析病患数据,整合跨系统的数据,查看需要优化的模式。
- 获得医疗保健人群的360度全景视图 使用分析模型去了解所有群组的行为属性,甚至能发现成本高昂的群组,让您能够前瞻性地管理问题。
- 衡量治疗方案的整体效果 创建治疗方案合规的统一视图,并以综合或更详细的视图报告其效果。
- 显著提高会员合规的可能性 自动化的会员沟通和响应系统,通过会员喜欢的渠道和要求的时间频率进行沟通。

更好的会员和成本洞察,在不断变化的市场取得成功
获得尽可能多的关于会员和索赔的数据。对业务方方面面更深入的洞察。能够与供应商协同工作提供全面持续的医疗服务。我们的解决方案可以帮助您管理您的数据并建立起坚实的健康分析基础。方案包含以下功能:
- 数据整合 确保轻松访问各种系统各种格式的所有索赔和运营数据。
- 数据质量 保证数据的一致可靠并始终保持最新状态,提高数据的使用寿命,确保分析结果值得信赖。
- 主数据管理 开发主数据管理计划,用来管控数据的一致性,创建数据的统一视图,实施更有效的数据处理。
- 数据可视化 以全新的可视化探索方式查看索赔数据,发现能够得出新洞察的隐藏模式和联系。
- 高性能分析 更快建立分析模型,比以往更快地获取洞察。让您能够有信心地做出更明智的实时决策。
将来自不同系统和平台的索赔、临床和其它大量数据转换成有用的信息。快速获得新的市场洞察。适应以消费者为中心的健康保险市场。只有SAS提供的广泛功能,可以推动您的分析能力达到最高的水平,从而可以:
- 打破信息孤岛保持数据一致性 通过标准界面快速连接通用数据源。利用灵活可扩展的数据整合平台,经济有效地整合现有和将来的数据。
- 分析所有相关数据 您可以分析所有的结构化和非结构化数据,了解会员和业务风险,成功管理最小或最大MLR。
- 实施可扩展的分析基础架构 利用内存处理技术,测试新的想法,评估更多场景。摆脱束缚。
