Healthcare executives at high-performing networks have learned through experience what drives their networks to achieve impressive results year after year. Now that they know what works, they’re not straying from that proven formula. In fact, they’re going one step further and sharing that knowledge to guide their peers on the right path forward – a path that is paved with data, data and more data.

The big idea is that many networks are not achieving their goals because they haven’t fully embraced a data-driven mindset or implemented a data-driven strategy. They’re still making assumptions about last year’s performance gaps and making educated guesses about why their shared savings fell short – but they don’t have real answers. That’s why they’re also not getting real results.

But what’s even more troubling is that they actually do have the answers. They just don’t know it. They’re simply not thinking about the knowledge that is hidden in plain sight – inside the messy, complicated, confounding, complex, but insight-rich claims data that is just waiting to be analyzed.

Considering Claims as Clues

To make smarter, more data-driven decisions and get the best results, healthcare organizations must not leave any stone unturned. Claims data is the much-needed foundation for a deep network analysis. A thorough analysis helps organizations to uncover hidden, actionable insights that are concealed within claims data – and then translate those findings into concrete strategies for improving results.

Every claim is a clue to help determine where patient leakage has historically occurred and where those patients received care outside the network. Every claim is a clue that points to gaps in care by specialty or by geographical service area. Every claim is a clue that points to proven, data-driven opportunities to improve. Without these real-world, claims-based insights, networks often tend to do more of the same – which wasn’t effective or effective enough.

Claims-based analysis can map provider referral patterns, track patient flows, identify sources of patient leakage and the recipients of that out-of-network (OON) spend, and calculate revenue and cost of care metrics. A claims analysis can deliver an interactive dashboard of patient leakage and provider behaviors, as well as heat maps indicating the gaps in coverage.

Claims Confirm Actionable Opportunities to Improve and Grow

A comprehensive claims analysis is always enlightening for network executives who have often spent years or even decades making decisions based on limited data or their own hypothesis. The clues that were just waiting for them in their claims data can be transformative.

Sometimes the data confirms their long-held assumptions while other times it provides a much different perspective on the network’s challenges. Most importantly, the claims-based insights are actionable. They are clearly defined. They are often minor changes that can produce major results. These new insights empower executives to take strategic action, with the confidence that their action will deliver quantifiable results.

Claims Case-in-Point

In one recent example, a Fibroblast client used their claims analysis to determine the best-fit OON providers to engage in discussions about forming partnerships or joining the network. They even discussed potential acquisitions of their practices which are still in progress. The client’s claims-based clues helped them to work towards their goal of reducing competition, adding to the network’s bottom line, and gaining more control over the quality of care that patients were receiving.

Would you like to uncover the clues within your claims data? Contact us to find out how we can help – and put your claims clues at your fingertips. Also, check out this case study about 90-Days of Provider Analytics in Action to learn more.