Network/Plan Changes and Impact

[Guest MarcP]

I am a computer programmer who has worked in the health care arena for the past ten years. Over the last year or so I have developed a system to help self insured entities control the cost of providing health care to their employee population. I am hoping to get some feedback from this group on the system. It contains 4 main applications:

Claims Review

This is a standard set of reports to help identify where claim dollars are going.

Some of the reports are: Cost by Benefit Category (Network & Non-Network Breakouts), Top Providers/Facilities, Cost by Diagnostic Category (MDC), Cost by Lifestyle Category, Network Savings

Trend Analysis

These reports show the cost trends broken down by the same set of reports listed above. Primarily I see these used for both early identification of (over) utilization and also to provide ROI validation of disease management & wellness programs.

Network Analyzer

Through the mining of historical claims that were originally repriced from a variety of PPO networks and the use of some algorithms I developed based off of this data and in comparison to the Medicare fee schedules I am able to take any distinct sponsors' claim set and reprice that claim set through all of the networks I have historical information on. I in turn can then reprice the fall out claims against the same networks that allow themselves to be 'wrapped' around another network for additional savings. I developed this in response to companies making network changes and basing the decision on discount averages supplied by the networks themselves and only being able to validate these discounts after a change has been made.

Plan Modeler

A user could define an entirely new SPD in the system and the Plan Modeler re-adjudicates that entire claim set to determine not only the savings/cost to the plan sponsor but also the exact impact to each employee. The user can use either an actual historical claim set or a historical claim set that was re-priced using the Network Analyzer.

I would like to see if these applications would provide sufficient value to their users or if there are other items that would be helpful to everyone.

If anyone would like to see the reports produced I would be happy to send them samples with blinded data, or I could send anyone a username/password for the website so they could run the applications against the companies loaded in the system (all data is blinded).

Thank you all in advance.

- Marc Pinkston