• Claims Analysis

    Consistently analyzing your claims data is key to managing health care costs.
  • Our consultants work with you to interpret claims data — helping you identify cost drivers, modify plan designs and implement initiatives to help you more effectively manage your health plans while promoting the health of employees and their families.

    If you are self-insured, our state-of-the-art claims analysis system monitors your claims on an ongoing basis. Our consultants use this system to help you control health care costs by eliminating waste, monitoring care and improving the health of your employees and families.

    Measures include:

    • Improving medical and Rx clinical compliance
    • Optimizing network performance
    • Benchmarking cost and quality (nationally, regionally and by industry)
    • Changing employee behavior through focused health improvement initiatives
    • Leveraging data to improve vendor performance

    Utilization & Cost Trends

    Look for measurable savings and plan design improvements from data analysis of ongoing program costs and utilization trends. We’ll proactively identify opportunities for vendor improvement and interventions — increasing member and provider service-level satisfaction and program financial performance.

    With data analysis, we can also help you devise the appropriate health improvement initiatives, plan design changes and incentive structure to improve your employees’ overall health.

    Multiple plans? We’ll address each one individually, as well as provide an overall picture.

    We routinely use the plan data to forecast financial impacts of plan design changes, develop targeted health improvement initiatives, implement appropriate employee and dependent contribution strategies and identify opportunities for improved vendor performance.

    For fully insured clients, we review the entire claim reporting resource to develop actionable strategies for the immediate plan year, as well as long term.

    Recent initiatives include:

    • Assessing the Carrier/TPA processes and performance for utilization review and management, large case management, disease management and preventive screenings. Developing and implementing process improvements to close performance gaps.
    • Proactive monitoring of client populations’ adherence to evidence-based care standards and comparisons to benchmarking data. We increased the accountability of vendors and implemented targeted programs to improve clinical outcomes.
    • Network performance studies to identify the most efficient providers in certain markets. Some clients are using this information to develop strategies for steering their plan participants to the best providers for certain procedures.

    National benchmarking for leverage and insight

    With your available data, we use industry benchmarking information from local, regional and national sources to continually assess the performance and competitiveness of your programs against a broad range of data sets. Our benchmarking data sources include:

    • Xerox Informed Health
    • Ingenix
    • Mercer
    • Milliman
    • Pharmetrics

    We typically include plan components, such as:

    • Plan features (e.g., deductibles, coinsurance levels, office visit co-pays, ER co-pays, formularies)
    • Enrollment and group demographics
    • Member cost sharing through plan designs and employee contributions
    • Chronic disease prevalence
    • Adherence to evidence-based care standards
    • Key medical and Rx utilization measures
    • Net plan costs
    • Provider discounts
    • Carrier/TPA administration fees

    We also provide you with access to a variety of modeling tools and software. With our modeling software, we conduct “what if” modeling to analyze the projected financial and member impact of specific plan design changes (i.e., modifying deductibles, co-insurance or co-pay levels) by reprocessing the most recent 12 months of medical or pharmacy claims.

  • For more information, contact one of our office locations.

Risk management, benefits consulting services and insurance products are offered through First Niagara Risk Management, Inc., doing business as First Niagara Benefits Consulting, a wholly-owned subsidiary of First Niagara Bank, N.A., and a licensed insurance broker and agent. Insurance policies are obligations of the insurers that issue the policies. Insurance products may not be available in all states.


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