INSURANCE COMPANIES WITH FULLY INSURED PLANS
Fully-insured health plan administrators are awash in data within legacy data systems, but access to actionable information is limited. Department level data systems tend to be siloed with competing information needs and limited access to IT personnel and resources.
The HRM system can be used in SaaS-mode with HCRM processing data from the carrier and various departments accessing the results via a secure internet link. It can also be installed in the Carrier data center on hardware and database software provided by the client. HCRM installs the system, provides IT training to run the system each month, supports operations with system updates and improvements plus on-going training and support to users.
* In Underwriting, actuarial tables generally provide accurate estimates of aggregate risks, it is the judgement of individual underwriters that identify potential large claims. Sophisticated predictive modeling systems can reliably predict costs at the member and group levels and identify high risk individuals.
* Large Case Management cannot be proactive by anticipating catastrophic risk. HCRM predictive modeling provides insight into existing large cases and predict future cases before they precert for high-cost care.
* Effective condition management with demonstrable results will help Carriers to retain ASO clients by better managing member health and reporting positive outcomes. Addressing the clinical needs of members with chronic conditions and effecting behavior change for better disease control and lower claims cost is highly desired by ASO health plans since there is a direct benefit to the client and better retention of low-risk business.
* Sales and Marketing benefit from accurate analytics by understanding the sources of “good” and “bad” business. Which broker/consultants have the lowest loss ratio, the highest closing rate and the fastest growth? Who can you encourage and who should be left behind? You grow the best garden by selecting the best plants.
Reporting Capabilities
- Risk and Profit Management: The system provides regular reporting of loss ratios, retention rates and high risk areas at the group and book of business level to maximize profitability.
- Underwriting: Custom group reports can be generated that reflect the specific risks the department wants to check. It can include forecast high risk/cost members, potential transplants, specialty drug use, top 10 forecast members, etc. to increase underwriting efficiency and quote generation.
- Care Management: Automatic reports identifying members with forecast costs above the spec alert level used by the care management team to engage with large case management and care coordination with provider. Outcome reports for such members are also available.