“You too can potentially save $50,000 in six months!” This phrase could be a headscratcher for some, or a lightbulb for others. A Benefitfoucs broker partner using Health Insights found themselves both scratching their head and turning on the lights. Intent on finding health plan cost needles in the claims data haystack, they got to work looking more closely at their medical claims data. As the data story unfolded, they found themselves in thick of the best laid plot, where in the end, the superhero saves the day!
The Tool and the Team
Health Insights is incredibly powerful, taking data aggregation and mining to invaluable insight that helps organizations identify and control health cost drivers. However, the Health Insights team is the fuel that keeps the machine running and providing insightful data and strategic partnership for brokers.
The Health Insights team recognized the need to normalize data filtering and analysis. They created several filters that would provide quick access to a detailed view of specific potentially high-cost services, including Emergency Room, Mental Health and Pregnancy. These filters were developed from the expertise of the Health Insights team to consider aspects of claims data like CPT codes, procedure codes and place of service.
But, what does this have to do with the broker’s success?
How did they get the data?
Since the broker was already working closely with their employer customer and was well engaged with the Health Insights tool, it was simply a matter of applying the proper technique. The broker already suspected some high costs were coming from ER visits, so they utilized the Emergency Room filter to start looking for claims data evidence of unexpected high cost. What they found was interesting and plotted the course for a lesson in informed action.
When the broker reported member and clinical analysis with the ER filter, they found that one member was going to the ER at a much higher rate than average. The member’s number of visits had increased significantly in the previous six months. At an expected rate of $1,200 to $4,000 a visit, the increase to multiple visits per week was adding up quickly. In fact, it had already cost an unexpected $50,000 in six months!
What did they do with the data?
The broker immediately shared their findings with the employer customer. They followed up by reaching out to the employer’s health insurance carrier on their behalf to figure out the best course of action. As a result, the member was established in the carrier’s Care Management program. A lot of the questions surrounding the increase in ER visits were answered and provided much needed insight into health plan utilization by members.
It turns out that the member could not find a primary care provider for the severe pain and anxiety they were experiencing. The ER became the solution for that member. Once in the Care Management program, the member had access to nurses, doctors and other specialists in the field. The member was directed and supported by the Care Management program and partner specialists (specifically pain specialists) to provide a regular and consistent level of care that fulfilled the member’s needs. They were educated and transitioned to an appropriate plan of care by Care Management.
The redeeming aspect of the story is that the broker brought a potential cost concern to their employer customer before it was ever even recognized by the employer or carrier. Since the specific member’s claims fell below the carrier threshold on cost and did not fall into a trigger diagnosis group, this threat was in limbo. However, the broker put their expertise – and Health Insights – to work. This specific member’s ER utilization dropped within a few months, helping to appropriately treat the problems they had and keeping the ER cost from skyrocketing. Secondly, this case opened the employer’s eyes to the necessity of establishing new measures to find and help these types of members well before they become a high-cost risk. The opportunity paved the way for even more successful broker/employer partnership through proactive action, communication and novel planning.
Communication is Key!
Perhaps the biggest take away from this situation is that communication on all levels is immeasurably important. First, communication is needed between all parties involved in the health plan and its administration. The broker immediately started direct communication with the employer and the carrier. This kind of engagement and customer advocacy made the process efficient and effective, as well as established expertise and trust in the broker partnership. Secondly, the broker guided communication from the carrier and employer to the member, which helped establish understanding among the parties and paved the way for a good outcome for both the member and the employer. In fact, on the broker’s recommendation, the employer set up regular communication to set the expectation of member interaction with administrators and their own health plan. Educational opportunities were programmed, and regular newsletters and emails were generated and sent out to members.
This broker effort worked on many levels. The broker utilized their expertise and tools in support of their employer customer. The broker and employer recognized that members may be looking for care or support, but they are not aware of their opportunities. The broker established a trust that allowed them to help create proactive and cost-saving programming to address member health. And, they used Benefitfocus Health Insights as a market differentiator to prove how they’re evolving and meeting change with success. Partnership at its finest.
So, how do you help your customers with Data, Communication and Action? Have you found the needle in the haystack?
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