First and foremost, we expect our carrier partners to perform due diligence to ensure proper claims payments that align with the plan documents and plan design. Diversified insists that our providers utilize claims review systems and processes, and we monitor those activities so that we can hold them accountable. Our Data Analytics team reviews carrier claims reports, hospital admissions data, and monthly claims details and loads this information into our data analysis and predictive modeling system.
When reviewing claims, our Data Analytics team looks for duplicate claims, overpayments, cost of benefits, and cost mitigation opportunities.
Review Claims Patterns
We believe it is essential to review claims patterns and look for efficiencies and cost savings before a claimant becomes catastrophic. For this reason, our team employs the power of predictive modeling, risk stratification, biometrics, and ongoing monitoring.
Taking Corrective Action
Our data analysis and predictive risk modeling systems allow us to isolate gaps in care, improper care, and risk factors to uncover conditions before a member becomes a large claimant. We then work with our carrier partners to intervene and improve member experience.
Large Claim Review
When appropriate, large claims are also reviewed and audited by our medical director who evaluates the appropriateness of care and course of treatment, to ensure that the member is receiving the most effective and efficient care, while looking for ways to mitigate costs.
We can deliver valuable insights into the claims reported within a given group through our Data Analytics team. With these insights, the trends and risks to the group population can be addressed with options that may include plan adjustments, wellness offerings, or disease management.