Business Objective
Our client is a major provider of health insurance plans in the US. The client expects member steerage to save significant medical costs and lower out-of-pocket expenses for members. They wanted to identify members with the likely need for a shoppable service(s) so that they can be steered towards cost-effective providers. More specifically, the client wanted to:
- Predict members that are likely to have a shoppable procedure (or claim) in the next 30 days
- Identify key drivers to enable member outreach team to intervene and steer members towards cost-effective procedures and providers
Challenges
- Large set of data running into 30 million rows per month
- Designing scripts for an outbound calling program, considering the involvement of stakeholders from multiple teams (digital engagement, member outreach, account management)
Solution Methodology
- Started with determining the top shoppable services that represent a sizeable opportunity for potential ROI – e.g., bariatric, musculoskeletal outpatient, ENT, imaging
- Created hypotheses to determine the factors that might be influencing a member to have a shoppable procedure – past claims, prior authorizations, diagnostic attributes, member characteristics
- Used a three-staged modeling approach to
- Predict members who will have a specific shoppable service/claim
- Predict members who tend to go towards high-cost providers
- Predict members who will be responsive to an outreach program
Business Impact
- Identified potential cost savings of USD 5 million for the client’s fully insured business
