Areas of Service
Data warehousing
Healthcare data of self-funded plans exist in multiple, non-standardized formats, including medical claim files, pharmacy claim files, enrollment files, banking records, and others. For plan sponsors tasked with critical decision making, this multiplicity in data sources and formats can hamper comprehensive clinical and financial analysis across the healthcare continuum of their beneficiaries.
Care Coordination Programs
Fragmented healthcare delivery can lead to poor health outcomes and increased costs to a plan. This is especially true of the small percentage of a plan’s members that account for the largest proportion of expenditures. ForP can identify these at-risk populations, and intervene at both the patient and provider level to better align resources, close gaps, and increase efficiencies.
Client Support
ForP assigns a professional Project Manager to each client plan for implementation and customer service. In addition, web-based or in-person tech support and training can be provided. Plan administrators and authorized parties can have 24-hour access to data and reporting via a web-based browser.
Predictive Modeling
Machine learning and predictive analysis applied to normalized data sets in the ForP Common Data Model allow plan sponsors to identify opportunities for better financial decision making. This can be particularly useful when benefits design changes are contemplated, or when plan sponsors wish to evaluate the proposals of competing vendors.
Real Time Claims Review
From a fiduciary standpoint, plan sponsors must confirm that a dollar-for-dollar correspondence exists between payments from the plan to its carrier/TPA and from the carrier/TPA to providers. In other words, the carrier/TPA should function as a ‘pass through” for plan assets. Nothing should be retained by the carrier/TPA. Examples of retentions include hidden administrative fees added to health claims, or overpayment recoupments and refunds not returned to the plan.
Utilization Analysis
Healthcare financial and clinical records in the ForP Common Data Model contain a vast amount of structured and unstructured data that can be mined for insights to improve quality, reduce costs, and drive resource planning. Forp analytical tools can “hot spot” retrospectively or in real time, identifying anomalous use of the system for targeted interventions.
Parallel Claims Adjudication
ForP can ingest enrollment, benefits, and plan design data into its contract management system, and can adjudicate member claims in parallel with the carrier/TPA. This system can automatically verify whether claims are being adjudicated in accordance with plan design and carrier contract, and that benefits are paid only to eligible participants. Errors can be identified in real time, before plan funds are released, avoiding the need for expensive recoupments in the future.