Health Claim Data Is Power

There are different types of gamblers in Las Vegas.

The first type sits at the slot machines and watches their money vanish with each handle pull. Sure, some win, but it’s rare and they usually give it back to the house with continued play. Then there are those that understand the game and know the odds. Since the odds are in favor of the house, these gamblers lose, but not as much and not as often. And then there are the card counters – the ones that have the data to beat the odds and mitigate risk. Let’s call that knowledge. The way the casinos mitigate their risk is by taking back the power and banning those gamblers from the table.

In the fully insured health insurance world, knowledge comes from claims data.

I have fought traditional insurance companies for years to get claims data. In order to preserve profits, insurance carriers hide behind excuses like “the client is too small to be credible,” or they provide incurred data with completion factors that aren’t specified. They’ll also stall so the most recent data isn’t available until months later.

The federal government is onto this, first taking action by requiring?hospital pricing transparency and now pharmacy benefits manager (PBM) transparency.

Transparency reduces the margins and?profits of these types of intermediaries and allows plan sponsors to make decisions using relevant and timely data points.

EPIC partners with Innovu, a data aggregator, to get timely data feeds from third-party administrators (TPAs) and PBMs – with line-item detail.

No longer do we have to wait for TPAs to get incurred data or run it through their analytics teams, creating skewed and stale data points. Now we can scan claims for trigger conditions (like renal disorders, which can be actively managed) and assess medical management effectiveness and discount adequacy. We can also provide essential benchmarking to expose manageable health plan cost drivers that are in excess of expected values.

The power pendulum for plan sponsors is swinging. With EPIC as your broker, you are a card counter – not a slots player.

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