Healthcare Analytics for Payers

Fraud, Waste, and Abuse Analytics

The healthcare industry loses billions of dollars every year due to fraud, waste and abuse.  Actian’s Analytics Platform enables fraud investigators to identify and predict improper billing patterns with speed and precision.

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healthcare analytics prevents fraud, waste and abuse

Payers Gain the Upper Hand with Healthcare Analytics

  • Detect and prevent incidences of fraud, waste and abuse prior to payment using data integrated from various sources, including medical and pharmacy claims, EMRs and more
  • Alert payers to fraudulent or improper patterns in real-time using highly accurate claims analytic models
  • Eliminate costly post-payment recovery programs
  • Calculate and continuously monitor normalized risk scores for suspect providers, patients and third party suppliers

Customer Engagement

Customer Engagement & Member Retention

As growth in individual health plan membership rises, it is becoming even more critical for health plans to optimize customer engagement in order to grow overall retention and increase customer loyalty. With Actian’s customer engagement solution, organizations will gain visibility into their population base to develop real-time customer-centric action plans.

Applying Science to Increase Retention & Reduce Attrition

  • Analyze your customer base and  perform micro-segmentation for personalized interactions
  • Identify, retain and nurture high value members through improved quality of service
  • Gather data from hospital, claims, call centers, social and web for increased accuracy
  • Gain insight into real member concerns before they escalate
  • Empower your organization to correct negative sentiment in real-time
  • Increase visibility into improving the consumer & member engagement process to help produce healthier, more engaged and more loyal members
  • Monitor improvements in health, re-enrollment, and risk profiles for each member and track the impact of implemented customer loyalty programs

Clinical Auto-coding (CAC) Audit

Actian’s CAC analytics tool enables organizations to maximize the effectiveness of the claims audit process as well as ensure that they are meeting their fiduciary and compliance obligations.

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CAC Audit

Deliver Higher Medical Coding Accuracy with Healthcare Analytics

  • Ensure claims are processed and paid accurately, and processed within plan compliance
  • Increase auditor productivity while reducing time to rework claims by eliminating time-consuming and error-prone manual processes.
  • Detect errors in coding and correct them with automated suggestions
  • Identify which claims can result in maximum efficiency and ROI
  • Automate the auditing workflow with machine learning algorithms
  • Evaluate the effectiveness of the claims system and refine internal policies and controls as needed, leading to reduced cost and increased savings


Claims Integration & Validation

With healthcare analytics, organizations can remove the barriers of long-processing cycles and gain immediate ROI on highly-accurate claims that run in a real-time environment by automating their claims preparation and validation process using Actian’s high-performance integration solution.

Claims Automation for Immediate ROI

  • Support member, claims, and payment data – with pre-defined schemas for all HIPAA required transactions
  • Eliminate long processing cycles with a platform that can transform millions of claims per day, leading to faster revenue
  • Improve first-pass rates
  • Validate and standardize data, improving the auto-adjudication process
  • Integrate EDI, HL7, HIPAA and ANSI data
  • Leverage real-time claims data to feed high-return healthcare analytics initiatives across the organization to improve cost, utilization, member retention, and outcomes
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