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Case Study: Healthcare

Charge Description Master complicated no more

Business Problem:

In healthcare insurance, it is difficult to quantify and verify that quarterly increases in payments to providers is within permissible limits as dictated by contract language, CDM, cap and attestation information

Abzooba Solution:

Healthcare Payers contract with various providers – physicians and hospitals – utilizing a Charge Description Master (CDM) which is a comprehensive list of billable items. For provider services linked to the CDM, there can be an increase in the amount billed quarter-over-quarter that needs to be either under the cap (agreed to by payers and providers) or agreed to through attestation (supplied by providers)

Abzooba used advanced statistical and machine learning algorithms – both in the discrete and continuous domains – to detect billing amount increases with high confidence.

We analysed all claims data and calculated the increase in quarter-over-quarter billing for different revenue and CPT codes.Increases determined quantitatively were checked against contract language to verify if they were allowed.For cost increases outside permissible limits, high confidence intervals were constructed to support the results.The final outcomes from the negotiations were incorporated as a feedback loop into the algorithms to improve accuracy.

Business Benefits:

IOver $50 Million detected in potential billing increases over permissible limits through a deep insight on historical provider behaviour that is extremely valuable in payer-provider contract negotiations