The document proposes a claims intelligence platform that will provide personalized insight and actionable intelligence to stakeholders like patients, providers, and payors. It will analyze claims data using machine learning and predictive analytics to generate real-time reports and recommendations. This will enable continuous process improvement by accelerating decision making, emphasizing proactive care, enabling new business models focused on value and outcomes, improving customer and provider relationships, and translating knowledge into practice.

1. Claim Intelligence Platform
Chandrashekhar P. More

2. Objective
Create a claims intelligence platform that will provide
personalized insight and actionable intelligence to
enable continuous process improvement.

3. Claims Ecosystem Convergence
Make Payment
Patient Finance
Service Service
Provider
Request Claims
Issue Payment
Request
Render Services
Render Services
Request Claim
for Services
Claims Process
Management
( Provider )
Make Payment
Policy
Processing
( Payor )
Service Provider
Management
Claims Information Cloud
Health Plan

4. Traditional v/s Proposed Approach
Traditional Proposed
Data Extraction and Reports
Report 1
Report 2
Report 3
Report n
Job 1
Job 2
Job 3
Job 4
Machine Learning
(Predictive Analytic,
Recommendation etc)
Real-time
Analytic Engine
Report 1
Report 2
Report 3
Report n
Reports
Personalization and Configuration
Job 1
Job 2
Job 3
Job 4
Service Provider
(Clinical,
Prescription etc)
Claimant
Stakeholders
– Finance,
Claim
managers
etc)
Claim Intelligence Platform
Source Target
Data Mashups

5. Claim Intelligence Platform
Intelligence
● Claims Performance
● - Least/Most Expensive Claims
● Claim Benefit Analysis
● Service Provider Performance
● Claims Density by
- Cost, Region, Service,Service Provider
● Pro-active care – eg Pharmacy forecasting
Analytics
● Trends by Service Consumption - Daily, Weekly,
monthly, Yearly
- Doctor Visit/Prescription etc
● Service Cost Distribution
- demographics, regions
Realtime or In Progress Analysis
● Key Performance Indicator Monitoring
● Spatial Claim Analysis
● Claims Aging by Stages
Case Management Analytic
● Claims Risk
● Situational Awareness – Demand Patterns, Care
requests, bottleneck analysis
Reports
experience
Historical
● Remittance
● Finance
- Reconciliation
● Marketing
● Claims Management
● Regulatory
● Service Provider
● Custom – Ad hoc
Benefits
Building continuous process improvement for
● Accelerated Decision Making
Emphasis on proactive care to meet health needs
● New Business Model
Payment based upon value and outcomes
● Customer Relationship Management
- Care effectiveness/visibility
- etc
● Service Provider relationship management
- Care standardization etc
- Quality measured and improved by rapid changes
in ecosystem
- Knowledge translated into practice

6. End