The COVID-19 vaccine approvals have given health systems (and payers) a glimmer of hope that the surge of acute patient COVID-19 admissions may be ebbing. As we anticipate a sense of normalcy, the shift for payer organizations will likely be toward planning our 2021 healthcare strategies.

This pandemic has directly impacted and, to some degree, transformed our healthcare system. There is a new emphasis on alternative care settings – such as telehealth for routine visits and ambulatory care centers for surgeries – and we’ve seen significant reductions in elective procedures and routine care. Naturally, decisions in 2021 need to account for these shifts, as well as the tsumani of care as we shift back to “normal.”

It’s time to ask payers, do your plans and product offerings reflect this?  Are you prepared to meet the healthcare needs of a population that has held off care due to the pandemic, has been isolated and experiencing increased rates of behavioral health needs, and may have exacerbated symptoms from unaddressed chronic conditions? How do you stack up among your peers regarding planning, rate setting, and specialist distribution? Access to the right data and competitive intelligence can help you plan with confidence.

Questions to Consider

  • Where are the opportunities to expand, optimize and innovate?
  • How do our rates and product designs compare to our competitors’ rates?
  • Are we monitoring our processes closely enough to detect fraud, waste or abuse (FWA)?
  • How can we remain innovative, responsive and competitive?

These big decisions often require hefty investments, and it’s therefore critical that your planning is informed by detailed intelligence. Smart decision-making based on detailed data will allow you to meet your members’ evolving needs and prosper in this competitive landscape. You can competently and confidently make real-world decisions to move your business forward, based on the best data available.

Payers often use their own internal claims data to support these decisions, but competitive intelligence derived from outside claims data can significantly bolster support for acquisitions, new markets, new contract rates, product design, service offerings, recruiting and price point negotiations. Let’s consider these four strategies in your planning:

#1: Contracting Requires Data

You’ve got to know your competition’s rates, so you come into contract negotiation informed and don’t end up under-or over-paying. The goal is to attract the right mix of entities or practitioners to meet your populations’ needs, at the right rate for your business’ success.

With de-identified claims data, you can answer many common contracting questions about where your rates stand and how they compare with competitors’ rates. You’ll be informed about the best contracted rates per provider, facility, procedure, claim and code. And you’ll be able to identify the high-value physicians and facilities you should contract with.

You’ll be positioned to negotiate effectively, evaluate provider contracting decisions, and strategize future network development — all based on detailed claims data.

#2: Expansion Planning Requires Data

Competition is a fierce driver for expansion. However, this process requires detailed intelligence to understand the target market’s providers, facility volumes, specialty distributions, relationships and rates.

With data outside of your own networks, your organization can confidently consider:

  • Acquiring another payer based on the target’s potential return on investment; market presence data and reimbursement rates will facilitate this assessment
  • Entering a new market based on local competitors’ service/procedure activity data
  • Offering new specialty services to expand market share based on data regarding service gaps

Utilizing de-identified claims data, you can acquire a full market view of expected activity, existing opportunity and current practice behaviors across payers. This wealth of data reveals reliable trends that can govern your healthcare strategies and planning.

#3 Product Design Requires Data

When healthcare strategies involve new product design, data can and should guide that process. The right data will provide you with a full picture of the market to support network design decisions regarding procedures, treatments, provider specialty mix, facilities, and additional support for your target member population.

With appropriate data, you can focus on key offerings:

  • Designing (or redesigning) products based on a clear understanding and unbiased view of what community needs exist in a target market, and ensuring members have access to the right practitioners, facilities and ancillary support
  • Assessing services, including practitioners and their practice experience, to determine new additions to your networks
  • Recruiting practitioners based on their value and influence in your market, to offer members the best treatment and care teams

#4 Detection Requires Data

Every organization must identify and mitigate their risk, including FWA. By looking beyond your in-network data assets, you can gain key investigative insights. The best data sources can shine a light on concerning trends, such as atypical billing behaviors, high service volumes, and unusual referral patterns. When problems are quickly addressed, you help minimize losses.

A review of de-identified claims data can involve:

  • Examining specialty procedure volumes both in- and out-of-network
  • Identifying suspicious billing behaviors during provider enrollment or while already in-network
  • Assessing potential risk when practitioners bill in excess of typical industry rates
  • Understanding disparities suggesting network providers would benefit from professional development or mentoring

The Success of Healthcare Strategies Depends on Good Data

Healthcare is always evolving, which challenges every payer to continue responding to their members’ needs. Innovation is necessary to stay competitive, and that requires the best claims data – which means the most competitive payers leverage both their own internal claims as well as a broader, external claims dataset for contracting, expansion, product design, and FWA decisions. With that intelligence, you have a clearer picture of your market – the key players, your best opportunities, and the potential risks – to move your business forward.

Download our e-book on competitive intelligence to learn more about transforming your business with the right data at the right time.