Charge Master Analytics for a Large Health Insurance Company

Industry: Healthcare

Introduction

Healthcare Payers contract with various providers – physicians and hospitals – utilizing a Charge Description Master (CDM) which is a comprehensive list of billable items. For provider services linked to the CDM there can be an increase in the amount billed quarter-over-quarter that needs to be either under the cap (agreed to by payers and providers) or agreed to through attestation (supplied by providers).

Project journey

Objective:

To quantify and verify that quarterly increases in payments to providers is within permissible limits as dictated by contract language, CDM, cap and attestation information.

Approach:

Abzooba used advanced statistical and machine learning algorithms — both in the discrete and continuous domains — to detect billing amount increases with high confidence.

For a given provider, we analysed all claims data and calculated the increase in quarter-over-quarter billing for different revenue and CPT codes. These increases are compared to cap and attestation information for the provider.

Increases determined quantitatively are checked against contract language to verify if they are allowable. For cost increases outside permissible limits, high confidence intervals are constructed to support the results. Given that providers have more detailed data, any analysis need to be both timely and accurate. The quantitative results were used in payer-provider negotiations. The final outcomes from the negotiations are incorporated as a feedback loop into the algorithms to improve accuracy.

The workflow for identifying providers with CDM discrepancies are shown in the Figure below:

Business benefits:

  • For a major payer, Abzooba detected over $50 million in potential billing increases above permissible limits.
  • This analysis provides deep insight on historical provider behaviour that is extremely valuable in payer-provider contract negotiations.
  • Abzooba provided fantastic statistical and analytic services with the highest integrity.