Utilization Analytics for Medical Management Leadership

Medical management leadership needs insights on utilization trends – normalized for rate increases, membership changes, and other variables. Understanding utilization trends can help UM teams better focus their energies on services with a spike in utilization. Medical management leadership lacks transparency into utilization numbers at the most granular level to make informed decisions and impact medical spending.

Health Sigma’s AI-driven Utilization Analytics to the rescue:

Health Sigma (HSI) has applied its Claims Analytics platform capabilities to this problem. HSI’s AI-driven claims analytics analyzes historical claims to identify trends normalized for rate changes, membership changes, and other variables that impact utilization.

HSI Claims Analytics Results:

For a payer, HSI’s analytics identified: 

  • 8% of reimbursement in 2020 were for services not reimbursed in previous years.
  • Generated a list of services reimbursed for the first time – for deeper dive review by the payer’s medical management team.
  • Flagged list of services with a significant jump in reimbursements – adjusted for rate increases and membership changes. For example, drug reimbursements and higher tier emergency admissions, normalized for reimbursement rates and membership, saw a steady increase in utilization.
  • Medical Management can refine UM policies based on the insights.

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