Emerging Insights #10

Theme:

Claims Analysis

Learning Theme:

Client value - health seeking behaviour or outcome

Source:

VimoSEWA, India

Segmenting claims data can provide insights into interventions to reduce claim costs

Segmenting claims data properly can take time and effort, but it is essential to properly understand the drivers of claims costs and to develop targeted interventions. One technique is to analyze the data on a per unit basis instead of looking at aggregate amounts. In India, VimoSEWA employed this step when analysing the claims data for a composite product that included health benefits.

Yearly claims data were analyzed on an aggregate and a per unit basis (e.g. number of hospitalisations per 1000 members per year). The data were then analyzed in various segments including rural/urban, diagnosis, age band, gender, and length of time enrolled, etc. By looking at claim incidence, cost and diagnosis per 1000 members per year, VimoSEWA more clearly observed trends and reduced the fluctuations in the data created by changes in membership and use of health care services.

VimoSEWA’s claims analysis showed that common water borne diseases and respiratory ailments, along with hysterectomies, were primary drivers of claims costs and in many cases, preventable. To address this, VimoSEWA created specific health interventions to educate women on how to prevent illness and to avoid unnecessary (and costly) hospitalisations. A pre and post assessment will be made of the impact of these health interventions on claims costs, and ultimately, the sustainability of the insurance program.

For more on analysing claims and VimoSEWA, see the VimoSEWA Learning Journey.

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