Using multiple analytical tools and skills, BSG® analyzes costs, experience and plan design options.
The Health Cost Sensitivity Model is a tool used to predict future health care utilization. Its projections are based on variables that determine the cost of health care for a given population, including demographic data, plan design features, the type of contracts in place and the level of managed care in place, as compared to best practice information. The Health Cost Sensitivity Model is designed for the following:
Help plan sponsors evaluate past performance.
- Predict future expenses and provide a framework on which to build a strategic action plan.
- Foster better-informed plan design decisions with respect to transfer of costs between the employer and plan participants.
- Set benchmarks for the current plan and help to identify the cause of changes in cost or cost allocation.
- Promote vendor accountability.
- Analyze and compare the discounts offered by various managed care organizations.
- Track initiatives and compare them to outcomes.
- Examine the risk potential of acquisitions or rolling another population into the current plan.
The Prescription Drug Rating Model provides a flexible basis for determining expected claims costs for prescription drug benefit plans offered under a managed care delivery system. The model can be used to calculate expected prescription drug claim costs under a variety of prescription drug plan designs and drug benefit management initiatives. The output allows
comparison of the expected cost to the actual experience of the plan. It also
determines the cost impact of implementing new plan designs and new contract terms.
BSG® uses the model to calculate composite expected drug claim costs for the age/gender mix of members, geographic area, contractual limitations, benefit design, trend, negotiated reimbursement, and drug cost management programs. It can also be used as a basis for evaluating competing Pharmacy Benefit Managers.
To compare benefit programs offered by two or more vendors, a fee schedule analysis is often conducted. Analyzing vendor fee schedules is a complex process. It is important to determine the impact of the vendor's negotiated physician fees on the actual claims the plan experiences. This type of analysis compares the usual and customary fees associated with procedures for a specific time period for the two or more vendors. The Fee Schedule Analyzer compares CPT code physician fees and converts the vendor fee schedule to a RBRVS factor, adjusting for geographic location and expected utilization. This enables
BSG® to determine the most cost effective fee schedule based on the claims experience of the plan.
The MDC model helps estimate the relative cost impact of varying stop loss levels for inpatient hospital episodes of care. The model applies to commercial members and presents results by Major Diagnostic Category (MDC). The model also provides
expected claim costs for high cost claims or large losses. The output allows you to compare the expected cost of large losses to the actual large loss experience of the plan. This information enables you to determine if the plan is experiencing high severity or high frequency of large losses.
BSG® can vary key assumptions such as member demographics, the definition of covered services and the assumed discount from the provider's billed charges. The user may also set case rates for selected surgical procedures (i.e. angioplasty) and estimate the relative savings versus fee-for-service.
The Dental Cost Sensitivity Model is a tool used to predict future dental care utilization. Its projections are based on variables that determine the cost of dental care for a given population, including demographic data, plan design features, the type of contracts in place and the level of managed care.
The GSM produces a composite health care cost area factor relative to nationwide targets based on the number of employees located in each geographical region. It is a general measure of the impact on the total medical costs due to geographic distribution based on observed utilization patterns and community billed charges.
PDSI is a nationwide proprietary database containing provider directories for a select number of networks. A number of reports can be generated cross-referencing these networks. The reports can provide detailed information on provider access as well as member disruption.
Intellimed is a database of hospital and physician data that providers are required to report to the State. Information such as cases, procedures, charges and clinical data are in this database. The Intellimed program allows numerous queries to be generated that can be customized based on the needs of the client.
The NCQA database contains insurance company quality information that is gathered by NCQA. Reports are generated comparing data to national averages.
InterStudy contains insurance company cost and market share information by geographical region called a Metropolitan Statistical Area
(MSA).
RBP and MSA studies identify geographical areas where a client has a large concentration of members and research vendor options in those areas to capitalize on the best plan for the population in a given area.
Laboratory Claim Analysis consists of reviewing the actual laboratory claims experience and the discounts by network compared to a laboratory program product discounts. This analysis was performed to examine the impact of implementation of a voluntary laboratory card program.
Contribution and Expense Analysis monitors the activity of the plan relative to accruals. It summarizes eligibility counts, premium payments and loss ratios and is also used to monitor Trust balances.
Monthly reserve calculations are used by some of our clients to "booking" self-funded plan reserves each month. Other clients use the reserve calculation as an overview of how the plan is running by monitoring the cost per employee column.
Calculation of projected self-funded plan costs and COBRA rates based on trend, three years of weighted claims data and enrollment, pooled claims, administration fees, PPO fees, stop loss premiums, utilization review fees, plan design changes are performed on an annual basis. These rates are calculated for medical, prescription drug, dental and vision self-funded plans. These rates can also be calculated to determine expected costs and proposed employee contributions for new subsidiaries and acquisitions.
A PPO plan analysis is performed to examine claim costs based on the vendor discount arrangements. The discounts are examined separately by hospital inpatient, hospital outpatient, physician and other claims.
An Employee Contribution Analysis calculates employee and employer costs based on varying percentage or specific dollar amount increases,
The Annual Experience Review is a report consisting of:
- Annual cost per associate compared to national averages,
- Summary of monthly claims and enrollment for medical, prescription drug, dental and vision plans,
- Comparisons of experience information to national and regional benchmarks,
- Large claims summary to monitor ongoing high claims, and
Demographic studies.
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