2018 Innovation Awards: Analytic-Powered Medicare Set Aside and Analytic-Powered Medical Reserve
From Business Insurance:
Calculating Medicare set-asides and medical reserves is an important part of the workers compensation claims process, but it has historically been a complex and time-consuming task, according to Deborah Watkins, CEO of Care Bridge International Inc. in Sarasota, Florida.
The process is used to calculate funds needed to pay future medical services related to a workers comp injury, which have to be exhausted before Medicare pays for treatment. The arrangements cap a payer’s future liabilities but can involve forecasts covering years of treatment costs.
Traditionally, claims professionals submit a proposed arrangement to the Centers for Medicare & Medicaid Services for review and approval.
“The problem was that we were providing this forecast using a methodology that has never been proven,” said Ms. Watkins, a former clinical nurse who has been involved in medical claims her entire career.
Companies that submit the arrangements rarely follow up with research to determine whether the amount agreed upon was an accurate number, she said. In addition, the process takes weeks to complete. By adopting a big-data approach to assessing future medical costs, Care Bridge can quickly produce costs assessments that are lower and more accurate than traditional methodologies, Ms. Watkins said.
The software solutions — Analytic-Powered Medicare Set Aside and Analytic-Powered Medical Reserve — won a 2018 Business Insurance Innovation Award.
Using a data warehouse of more than 12 million claims, “a third-party administrator, carrier, self-insured or even a law firm can actually perform a data integration request using a dropdown menu to answer questions, and the variable is sent to the data warehouse where we find similar claims, and we are able to use predictive models to provide a reasonable and probable future care analysis,” she said.
The analysis is returned immediately at half the cost of the traditional reports, and claims can be settled months faster, Ms. Watkins said.
In addition, the data can be used to create an analytics dashboard to monitor compliance and measure and monitor reserves in real time, enabling users to establish benchmarks and identify problems, she said. Because of the speed of the response, users can obtain the valuations while they are mediating claims. In addition, the product can be used to validate existing reports, Ms. Watkins said.