Situation 
Who doesn’t want to make sure your payers are meeting agreed upon contracts?  Monitoring contracts is more than just having an employee reviewing large contractual write-offs or denials.  You need to be able to aggregate data to find trends and then drill into the details.  Prominence worked with a customer to do just that!
The organization wanted to gain insight into their costs, volumes, claims, and membership metrics across their payers to identify potential cost-saving scenarios and profitability opportunities. The Employee Benefits team needed the ability to analyze their Employer Plan claim files to gain insight in their providers’ utilization costs, as well as to monitor their members’ level of medication compliance required to manage chronic health conditions.

Previously they were unable to:

• Trend data month to month
• View data across payers
• Reference data against benchmarks and contract terms
• Identify cost or payment opportunities

Task 
The Prominence team was tasked with aggregating ten different monthly files received from their payers, which included claim, pharmacy, PMPM costs, and membership files.

We were asked to:

• Use our expertise in databases and data modeling to build an infrastructure that would map files across payers
• Develop a scalable solution for additional payers as new information is collected and available
• Design standard views as well as ad-hoc query capabilities
• Develop a method to ensure that certain fields in the claims data were removed as early in the process as possible, since they contained sensitive information

Action 
To start, the Prominence team built an architecture to facilitate the mapping and combination of claims files, allowing the organization to trend information over time and analyze metrics across multiple payers. Next, we built an application that allows metric comparison across providers, facilities, and payers.

The goal of the application is to guide users in identifying potential problems, such as:

• High costs patients. Why are the costs high? What workflows caused the high cost?
• High cost patients going to outside facilities
• Patients that have not been seen in their network for specific timeframes
• Pharmacy prescription substitutes scenarios that could potentially drive down costs