High-risk Claims Analysis

 

Facilitates early intervention of potential high dollar claims.

American Health’s High-risk Claims Analysis service facilitates early identification of members who are at risk for generating high dollar claims.  Additionally, it identifies potential cost savings opportunities through proactive case management intervention.

Studies show that approximately 4% of a covered population suffers from chronic illness and accounts for as much as 50% of the total medical cost for the population.  Up to 50% of the costs incurred by the chronically ill arise from their failure to understand and manage their physician’s treatment plan properly. 

High-risk Claims Analysis can help by identifying these members sooner and intervening through Case Management when appropriate.

 

Fast Facts

• Focus is placed on identifying chronically ill members who are at risk for future high-dollar claims, and captures these members earlier than traditional methods that focus on episodes of catastrophic illness.
• Analyzes patterns of utilization that may indicate adverse changes in health status such as a new diagnosis, recurrence of a disease or unstable, chronic illness.
• Case Management referral is initiated when potential for Case Management impact is identified.
• Integration with Prospective Case Management provides patient-centered needs assessment, education, coaching and support, monitoring and guidance on home or outpatient services.
• If additional investigation is needed to determine potential for case management impact, a research case is initiated. Clients receive a report of the findings 30 days after research is initiated, as well as a recommendation for the initiation of case management services if needed.