Health insurance claims data can provide a wealth of knowledge—if you know where to look. Whether you review your program’s claims activity monthly, quarterly, or bi-annually, the process can allow you to see how the year is progressing and year-over-year performance. Think of it as an insurance plan barometer, helping identify any trouble areas that could arise. It can also be used to help you anticipate and prepare for any potential plan increases the following year.

Here are three data points to start making data-informed decisions that can help you optimize your cultural exchange accident/sickness medical insurance plan using the claims reports you already receive.

1. Are atypically large claims derailing your plan?

Large claims can and do happen, but they shouldn’t upset an otherwise stable insurance plan. However, they can affect your claims experience.  Large-dollar claims can be considered either a normal trend or an unusual occurrence. If the large-dollar claims are part of a normal trend, then they will be factored into your insurance rate going forward.

If they are considered atypical, nonrecurring large insurance charges—such as an acute condition resulting in a lengthy inpatient stay or a complex surgery—they should be separated and pooled with your carrier’s portfolio of other large claims. If you discover a large atypical claim, ask your broker if that charge is being removed from the completion factor or how it is being discounted from the experience. Familiarizing yourself with your claims trends through regular conversations with your broker will help you identify anomalies within your participant health plan as they occur, and potentially save you from a higher premium during renewal.

2. Are participants seeking care where you want them to?

Because network providers are typically more cost-effective for both the insured participant and the plan provider, in-network care, as opposed to out-of-network care, is the preferred option. A claims report can uncover behaviors that drive up plan costs such as the number of participant health care services being provided in-network.  Armed with this data, you can compare current participant activity to your program’s goals and evaluate whether or not there is a need to drive participant behavior.

Find the total allocation for in-network versus out-of-network services section of your claims reports.  Because large claims amounts can have an outsized effect, allocation data alone doesn’t tell the whole story. Examine allocation amounts in conjunction with the specific numbers of in-network and out-of-network claims to monitor out-of-network provider usage, and create program participant outreach strategies before those expensive out-of-network visits get out of hand.  If you find that 85 percent of payment allocations are in network, but only 50 percent of all total claims are filed in network it might be time to increase awareness of health care options.

3. Is there excessive emergency room use?

Your claims report can also reveal if your participants are making too many trips to the emergency room—a common problem, especially within international populations who are unfamiliar with alternative health care options. An average ER visit can often lead to claims exceeding $2,000, proving costly for both participants and health plans.

Use emergency room claims data from previous years or, if available, other programs, to provide a valuable frame of reference. Consult with your broker to determine how your program’s emergency room claim amounts compare to claims from other providers during the same period.

Check to make sure you understand what practices your plan’s claims administrator has in place to obtain proper discounts, adjudicate claims that may arise from non-emergency care, and remove unreasonable charges (whether or not they are emergency room claims).

Reviewing claims data before your annual policy renewal date can help pinpoint activities, utilization behaviors, or trends that will influence important decisions about your plan, such as the changing of a benefit offering or the incorporation of a different network.

If diving into data analysis seems daunting, there’s good news—you’re not alone. Your broker or health plan provider can be a valuable partner in the process by regularly reviewing claims data with you and conveying what that data means for your program.

Schedule a claims data review to more fully evaluate the intricacies of your cultural exchange program’s accident/sickness medical insurance plan and manage it more strategically and sustainably.

-Michael Babore

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