Health Insurance Consulting Services

For health insurers, traditional business intelligence is not enough to meet today's needs. Qualex's solutions can provide you with forecasting, predictive modeling and optimization capabilities that can improve inefficient business processes.

SAS for Disease Management delivers accurate, timely information that enables you to predict risk and optimize interventions, so you can achieve improved outcomes. By leveraging award-winning data warehousing and data mining software for predictive modeling, SAS for Disease Management goes beyond traditional disease management solutions to offer:

A single view of the patient or member.
Advanced analytics for predicting risk.
Optimization of interventions.
Improved clinical outcomes.

SAS for Disease Management supports the four-step disease management process:

Data Acquisition and Management
Medical and pharmaceutical claims are the core information source for most disease management activities. However, claims records are designed to facilitate billing — not to provide a complete representation of population health characteristics. The SAS solution supplements claims data with data on membership and provider eligibility, pharmaceutical records, in-patient and out-patient billing, dental and vision billing, lab results and medical assessment questionnaires. The result is a more complete picture based on a variety of data sources.

Identification and Severity Classification
The SAS solution uses a variety of methods for identifying patients and assigning a severity classification, including:

Pre-designated lists (as determined by medical evaluations and diagnoses or hospital discharge data).
Rules-based algorithms based on diagnosis or procedure codes, pharmacy scripts, lab results and medical assessment questionnaires.
Advanced analytical methods, such as data mining.

Intervention
The SAS solution supplements the critical business activities associated with the intervention stage by:

Optimizing the intervention method by using data mining techniques to increase the likelihood of first contact and predict which intervention method may be the most effective.
Employing advanced reporting capabilities, such as scorecards and Web-based reporting, to facilitate the intervention process.

Outcome Management
The SAS solution supports both utilization and expenditure reporting to track the progress and effect of the disease intervention.

By leveraging award-winning data warehousing and data mining software for predictive modeling, Qualex goes beyond traditional disease management solutions while supporting the four-step disease management process:

Data Acquisition and Management
Identification and Severity Classification
Intervention
Outcome Management

DOWNLOADS

SAS for Disease Management Brochure

SAS Fraud Detection & Prevention for Health Insurance Brochure

SAS for Health Plan Reporting Brochure

Using advanced analytics, Qualex goes beyond traditional rules-based fraud detection solutions, thereby easily integrating your claims payment processes to improve recovery and prosecution efforts.

SAS for Health Insurance Fraud goes beyond traditional rules-based fraud detection solutions to offer advanced analytics that enable you to make predictive, accurate claims decisions before claims are paid. The solution integrates easily with your claims payment processes to improve recovery and prosecution efforts. SAS for Health Insurance Fraud supports a four-part process flow:

Data acquisition and management
The SAS solution accesses a variety of data sources — including medical and pharmaceutical claims, provider enrollment information and more — to uncover all leading indicators of fraudulent activity. SAS can also access existing fraud recovery data marts so you can make use of information that is already available. All relevant data — regardless of the source — can then be combined into a data model for further exploration and analysis to uncover links and identify relationships between patients, providers and services.

Outlier exploration — fraudulent claims and provider analysis
The SAS solution drives proactive investigations by automatically uncovering previously undetected relationships. This knowledge can be used for predictive modeling techniques, neural networking and other statistical procedures, and then reported in a variety of ways depending on user needs.

Integration with claims payment process
The SAS solution uses predictive model scoring to help you identify suspicious patterns and links to submitted claims so you can slow the inappropriate disbursement of claims funds and focus on prosecution versus recovery efforts.

Recovery and prosecution
The SAS solution helps optimize the recovery and prosecution process by helping to deploy information investigators, determining the likelihood of recovery and raising alerts or flags where appropriate.

Qualex can help you get medical cost management information directly into the hands of decision makers, where it belongs. And by enabling you to off-load basic query and reporting functions, the solution helps you reduce costs.

SAS for Health Plan Reporting relieves these burdens by providing your customers with direct access to the information they need in an on-line, self-service format. This solution meets the specific needs of the benefits professional by providing:

Superior data integration for easily pulling together data from multiple claims systems.
An easy-to use, point-and-click portal interface for seamless, immediate access to reports and analysis.
A prebuilt data model and reporting templates.
Drill-through capabilities to track medical costs by provider, location, benefit plan, product type, clinical category and place of service.

SAS for Health Plan Reporting gets medical cost management information directly into the hands of decision makers, where it belongs. And by enabling you to off-load basic query and reporting functions, the solution helps you reduce costs and the IT cycles associated with supporting employer reporting demands, while maximizing the value of your informatics staff.