Health Insurance Payor

new-magazine-graphic-whitePayor Analytics For Health Insurance Plans

Risk Management, Compliance & Master Data Management

In a recent study, Himss found 60% of C-suite Payor[1] executives surveyed said they are looking for analytics solutions to solve new business needs due to the Affordable Care Act (ACA).  Payors noted three primary business drivers:

  • New levels of risk resulting from ACA: Payors need to manage these by leveraging robust analytics solutions (namely, predictive and comparative analytics tools) that can help them better understand and address issues around risk modeling, the post enrollment risk environment and exchange risk structures.
  • New reporting and compliance requirements: The two key national quality initiatives — the Healthcare Effectiveness Data and Information Set (HEDIS) from the National Committee for Quality Assurance (NCQA) and Star Ratings program from The Centers for Medicare and Medicaid Services (CMS) are creating reimbursement risk.
  • Expanded depth and breadth of data to be analyzed: Various data sources must be analyzed to identify and drill down on cost drivers at the condition, member, physician, and hospital level.

Making Payor Analytics Pay Off With Faster Time-To-Value

To address these business drivers, Payors must implement extensive analytics capabilities rapidly to attain reporting, compliance and profitability targets. However, this also requires integrating a wide range of data types and sources to create meaningful analytics reporting.

Thus, we created the Fusion Health Advantage® Payer Data Model capable of ingesting data from both internal and extern data sources.  Additionally, the Fusion Health Advantage® data model leverages the Master Data Management (MDM) solution architecture, allowing distinct data sources to be mapped seamlessly into a single system of record.  This approach allows Payors to easily perform ad-hoc, routine and on demand analytics for metrics including:

  • Network Development
  • Member and Patient Registry
  • Claims Management
  • Business development

  • Risk Assessment
  • Inpatient and Outpatient Management
  • Population Health Management
  • Cost Control

Provide Every Member Of Your Payor Organization With Business Insights

To satisfy the quantitative analytics needs of today’s Payor organizations, multiple roles within the organization must be provided with distinct information related to their goals and perspectives.  The Fusion Health Advantage® Payor data model enables operational, financial and medical/CMD metrics to be tracked.  Our Payor analytics solution empowers operational and financial insights including:


Manage Risk Faster With Fusion Health Advantage® For Health Insurance

CMS is increasingly tying reimbursement for Medicare services to patient outcomes; thus, payors’ Star Ratings are being used by CMS to determine reimbursement to payors. Payor risk is now less known and more highly scrutinized for reimbursement.

Reduce your risk by leveraging our experience solving Payor analytics challenges.

[1] “A Look At What’s Driving Payors Use Of Analytics.” Himss. 17 December 2013. Web. 27 July 2015. Link