Health Plans & Payers Need MDM for Better Operations and Analytics

An estimated 70% of provider-submitted claims have missing or incorrect data. And claims that are missing data are more likely to result in improper payments. In fact, CMS estimates that 88% of improper Medicaid payments stem from insufficient documentation. 

When information is missing, claims processors must spend costly time filling in the blanks — Forecasting becomes more difficult. And patients may be caught in limbo between payer and provider, unsure what they actually owe.

Meanwhile, new regulations like the No Surprises Act mandate that accurate, timely provider contract info be shared with healthcare delivery systems and patients — even as 20 to 30% of physicians change affiliations each year. 

A complete, trusted view of all data about a member and their claims helps overcome these challenges so that claims are processed faster and more accurately — improving member engagement and provider satisfaction. 

Today, we’re applying three decades of experience working with organizations across health to bring intelligent data management to health plans and payers. With IMT’s solutions for Health Plans & Payers, we’re helping health plans gain a single view of members across all encounters and providers. But that’s just the start. Read on to learn what that single, trusted view can do for you.

Reduce claims handling costs

Automating claims processing saves time, effort, and money. But too often, claims must be manually reviewed to verify relationships or reconcile potential discrepancies. Health:iDM for Health Plans & Payers delivers a single, 360° view of the member and their household across all healthcare encounters and providers — automatically connecting members and dependents to reduce the need for hands-on reconciliation. This decreases the need for costly remediation that slows down claims processing.

Leverage relationships to improve engagement and outreach

Healthcare data isn’t always one-to-one or linear Rather, a single patient may see several different providers across multiple health delivery systems. And the providers themselves are constantly shifting affiliations through mergers and acquisitions. 

In fact, when CMS reviewed 5,602 providers at 10,504 locations, they found nearly half of provider directory locations had at least one inaccuracy.

We can help you better understand the hierarchies and relationships among all the providers you work with — as well as understanding the relationships between households, members, and dependents.  

Identifying these relationships helps you better identify abuse, fraud, or duplicate payments. 

Improve forecasting through analytics

Predictive analytics can support automated decisions and workflows, while more accurate utilization reporting can forecast future costs. Analytics can also generate performance scorecards and bundled payments, further restraining costs while improving efficiency.

But analytics are only as good as your data. That’s why we’re helping you improve your data quality so you can trust the analytics and resulting insights.

Ensure compliance with changing regulations

The regulatory landscape is constantly evolving, and the No Surprises Act that recently went into effect raises the stakes for having high-quality data. We can help you with compliance by delivering accurate data that you can report on. Plus, you’ll have the agility to add or update data elements to comply with future regulatory changes. 

Learn more about our Health Plan and Payer solutions, or schedule a conversation to discuss your specific needs