Data Driven Cost Recovery

Aggregating Disparate Data for Better Business Decisions

Our Client

Our client operates an innovative model of coordinated healthcare for dual-eligibles—people who qualify for both Medicare and Medicaid. Currently operating in two states, it ranks among the fastest-growing private companies in the U.S.

The Background

A spike in claims expense prompted company leadership to seek audit assistance to better understand their benefit spend. In essence, our client needed data warehouse capabilities without the wait or expense required to create one of their own.

The Challenge

• Enrollment and claims data existed in four separate files involving three organizations and varying naming conventions for data elements.
• Opportunities to examine for benefit leakages needed to be brainstormed with company leaders

The Blue Slate Solution

The first step in accessing the power of this organization’s data was to aggregate claims information existing in three different systems, being processed by three separate organizations and align expenses by member through incorporation of enrollment detail. All files were exchanged and ePHI masked utilizing HIPAA compliant methodologies. The second stage involved working with the company’s subject matter experts to tag the data in a variety of ways to enable targeted analysis to occur. The organization had identified a series of business decisions and benefit limitations which they wanted to better understand.

Analysis provided specific cost associated with business decisions which enabled leadership to make informed alterations to those policies. Benefit leakage associated with claim activity falling within contractually arranged per diems was identified and actions initiated to collect inappropriate payments. Blue Slate was asked to identify and quantify other various categories of claims to help resolve error patterns and prevent further leakage.

Comprised of in-house experts in healthcare, external data, security, rules harvesting, and business analysis, the customized Blue Slate team created a solution with the following components:

• Data aggregation. Team members collected data files from four disparate sources and, by identifying relevant data components and relational elements, built them into a single data warehouse.
• Security of personal health information. Using Blue Slate’s data security plan, the team moved and aggregated data according to all HIPAA standards for privacy protection.
• Industry business rules harvesting. Blue Slate team members worked with client subject matter experts to harvest business rules using Blue Slate’s rigorous process and rules capture methodology.
• Internal business rules development. The Blue Slate team, together with the client’s subject matter experts and functional leaders, drew up a rule set to identify specific criteria for driving out raw data leakage.
• Data transformation. Using its expertise in claims-based data modeling and analysis, the Blue Slate team transformed the client’s raw data from multiple disparate files into a single, secure, flexible database. This database applied business rules, reporting, and analysis to help client executives understand the costs associated with their dual-eligibility coverage decision.

Successful results in examining accuracy for one of the identified benefit leakage opportunities equated to a 19.3% administrative PMPM cost reduction and ROI of 2500%. In addition and just as important, executive leadership had access to a variety of results that quantified past and could shape future business decisions.