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5 Shades of Analytics…………………………………………...
CIO, Xerox Insurance Solutions & StrataCare
Michael Josephs
© 2015 StrataCare, A Xerox CompanyAll Rights Reserved.
Xerox is a leader in providing data incursion and Software-as-a-Service (SaaS) solutions to support the timely, accurate, compliant and secure payment of medical bills for the largest payers of Workers Compensation related claims
Processes over 24M medical bills annually, representing over $20B in billed medical charges
Context – Xerox Insurance and WC Solutions
2
Workers’ Compensation (WC) are state-legislated programs (except for federal government
employees) created to provide compensation for employees suffering on the job injuries or illness
Key Players in the WC ecosystem
– Employer: required in most states to provide employee benefits for work related injuries/illnesses
– Insurance Company: affords claims management and wage replacement, rehabilitation as well as survivor benefits
– TPA (Third Party Administrator): manage state mandated benefits for self-insured or those employers with large deductibles/retentions
– Service vendors: e.g., Medical Providers, Data Incursion, Medical Bill Review, Managed Care, Loss Prevention
© 2015 StrataCare, A Xerox CompanyAll Rights Reserved.
Context – Xerox Insurance and WC Solutions
3
Workers’ Compensation (WC) are state-legislated programs (except for federal government
employees) created to provide compensation for employees suffering on the job injuries or illness
Rule-Driven Configurability for Tailored Workflows
Supply Chain Connectivity
Decision Support Drives Workflow and
Supply Chain Optimization
– Balance Cost: Supports balancing level of near term operational costs with longer range outcome costs
– High Visibility: Provides illumination of operational efficiency levels and opportunities for improvement
– Ecosystem Refinement: Supports continuous improvement of supply chain efficiency
Data-Driven Decision Support
Xerox is a leader in providing data incursion and Software-as-a-Service (SaaS) solutions to support the timely, accurate, compliant and secure payment of medical bills for the largest payers of Workers Compensation related claims
Processes over 24M medical bills annually, representing over $20B in billed medical charges
© 2015 StrataCare, A Xerox CompanyAll Rights Reserved.
$
Increasing levels of value, investment and complexity
Shades of Analytics Function Xerox Insurance Analytics Assets
Prescriptive Analytics Makes specific outcomes occur ˗ Network Optimizer (patent US 8,700,426 B2)˗ CONNECT™
Predictive Analytics Suggests what outcomes will occur ˗ SCORE ™˗ SCORERX ™
Interpretive Analytics(aka Diagnostic Analytics)
Insight in to why an outcome occurred ˗ Client stewardship reporting˗ PPO leakage tools˗ Fraud, waste and abuse ID tools
Descriptive Analytics (aka Metrics)
Describes what outcomes have occurred ˗ SaaS-based self-service reporting platform˗ Real-time dashboards for Operations and
vendor performance
Shades of Analytics
4
Scalable private cloud-based Infrastructure, providing secure, compliant custodianship for sensitive medical information
256M Medical Bills, 71M WC Claims (reflecting all domestic jurisdictions, procedure and diagnostic types)
4
© 2015 StrataCare, A Xerox CompanyAll Rights Reserved.
But We Want More!!
5
Scalable private cloud-based Infrastructure, providing secure, compliant custodianship for sensitive medical information
Shades of Analytics Function Xerox Insurance Analytics Assets
Consumable Analytics Automates Making specific outcomes occur ˗ Pilots in progress or product planning
Prescriptive Analytics Makes specific outcomes occur ˗ Network Optimizer (patent US 8,700,426 B2)˗ CONNECT™
Predictive Analytics Suggests what outcomes will occur ˗ SCORE ™˗ SCORERX ™
Interpretive Analytics(aka Diagnostic Analytics)
Insight in to why an outcome occurred ˗ Client stewardship reporting˗ PPO leakage tools˗ Fraud, waste and abuse ID tools
Descriptive Analytics (aka Metrics)
Describes what outcomes have occurred ˗ SaaS-based self-service reporting platform˗ Real-time dashboards for Operations and
vendor performance
256M Medical Bills, 71M WC Claims (reflecting all domestic jurisdictions, procedure and diagnostic types)
$
Increasing levels of value, investment and complexity
© 2015 StrataCare, A Xerox CompanyAll Rights Reserved.
Vanilla – How Everybody Does It
6
Production Environment
Medical Bills Claims Admin Settings Workflow Rules PPO Network Mosaic
ETL
De-Normalization
Client Data Warehouse
Client Database
Mirror
Replication
MicroStrategyClaims Update
Bill In-take
Client or Client Vendor
Client Database
“Production”
Client Data Warehouse
© 2015 StrataCare, A Xerox CompanyAll Rights Reserved.
Vanilla – How Everybody Does It
7
Production Environment
Medical Bills Claims Admin Settings Workflow Rules PPO Network Mosaic
ETL
De-Normalization
Client Data Warehouse
Client Database
Mirror
Replication
MicroStrategyClaims Update
Bill In-take
Client or Client Vendor
Client Database
“Production”
Client Data Warehouse
© 2015 StrataCare, A Xerox CompanyAll Rights Reserved.
Where the Really Fun Things Happen
8
Production Environment
Client Stewardship & Support
. . . .
Customer Reporting
Network Optimizer
. . .Fraud & Abuse Detection
Network Leakage Detection
Analytics R&D
:
ETL
De-Normalization
Client Data Warehouse
Client Database
Mirror
Replication
MicroStrategyClaims Update
Bill In-take
Client or Client Vendor
Client Database
“Production”
Client Data Warehouse
Enterprise Data Warehouse
ETLDe-Normalization
ETLDe-Identification
Medical Bills Claims Admin Settings Workflow Rules PPO Network Mosaic
© 2015 StrataCare, A Xerox CompanyAll Rights Reserved.
Shades of Analytics Function Xerox Insurance Analytics Assets
Consumable Analytics Automates Making specific outcomes occur ˗ Pilots in progress or product planning
Prescriptive Analytics Makes specific outcomes occur ˗ Network Optimizer (patent US 8,700,426 B2)˗ CONNECT™
Predictive Analytics Suggests what outcomes will occur ˗ SCORE ™˗ SCORERX ™
Interpretive Analytics(aka Diagnostic Analytics)
Insight in to why an outcome occurred ˗ Client stewardship reporting˗ PPO leakage tools˗ Fraud, waste and abuse ID tools
Descriptive Analytics (aka Metrics)
Describes what outcomes have occurred ˗ SaaS-based self-service reporting platform˗ Real-time dashboards for Operations and
vendor performance
5 Shades of Analytics
9
Scalable private cloud-based Infrastructure, providing secure, compliant custodianship for sensitive medical information
256M Medical Bills, 71M WC Claims (reflecting all domestic jurisdictions, procedure and diagnostic types)
$
Increasing levels of value, investment and complexity
© 2015 StrataCare, A Xerox CompanyAll Rights Reserved.
Score
10
• SCORE™: Workflow management decision support capability which projects claim progression so that resources are applied strategically to at-risk WC claims
• SCORE
˗ Leverages neural network/predicative modeling techniques to assesses claim risk on a predetermined scale
˗ Leverages employer-specific (current and historic) data to develop models, then continuously scores each claim adjusting the score according per the clinical and medical bill updates
• SCORE’s Value to Clients
˗ Significantly impacting claim outcomes and reductions of care management expenditures overall.
˗ Senior management’s ability to obtain a snapshot of the total risk exposure of all open claims
© 2015 StrataCare, A Xerox CompanyAll Rights Reserved.
Consuming the Score
11
Client Database
Mirror
Replication
Claims Update
Bill In-take
Client or Client Vendor
Client Database
“Production”
Model Deployment and Execution● Daily updates of identified SCORE parameters are loaded to staging DB● Updates are applied to the models● Updated claim “SCORE” made available
Client Database
Mirror
SCORE Staging DB
ETL
SCORE Models
11
© 2015 StrataCare, A Xerox CompanyAll Rights Reserved.
Consuming the Score
12
Client Database
Mirror
Replication
Claims Update
Bill In-take
Client or Client Vendor
Client Database
“Production”
SCORE Staging DB
ETL
“Score” made available via Web API
1.“Score” made available for consumption by Xerox client platforms 3.“Score” delivered via e-mail
Multiple “SCORE” Delivery options: 2. Made available via the financial validation workflow
3. Delivered via e-mail to a specific resource (or resource group)
1. Consumption by client’s Nurse Case Management (NCM) platform
WorkflowConfiguration
SCORE Models
AdjusterPortal
2.“Score” made available to Financial Validation
© 2015 StrataCare, A Xerox CompanyAll Rights Reserved.
Shades of Analytics Function Xerox Insurance Analytics Assets
Consumable Analytics Automates Making specific outcomes occur ˗ Pilots in progress or product planning
Prescriptive Analytics Makes specific outcomes occur ˗ Network Optimizer (patent US 8,700,426 B2)˗ CONNECT™
Predictive Analytics Suggests what outcomes will occur ˗ SCORE ™˗ SCORERX ™
Interpretive Analytics(aka Diagnostic Analytics)
Insight in to why an outcome occurred ˗ Client stewardship reporting˗ PPO leakage tools˗ Fraud, waste and abuse ID tools
Descriptive Analytics (aka Metrics)
Describes what outcomes have occurred ˗ SaaS-based self-service reporting platform˗ Real-time dashboards for Operations and
vendor performance
5 Shades of Analytics
13
Scalable private cloud-based Infrastructure, providing secure, compliant custodianship for sensitive medical information
256M Medical Bills, 71M WC Claims (reflecting all domestic jurisdictions, procedure and diagnostic types)
$
Increasing levels of value, investment and complexity
© 2015 StrataCare, A Xerox CompanyAll Rights Reserved.
Network Optimizer
14
• Xerox has patented (US 8,700,426 B2) an analytical tool (the Network Optimizer) which allows it’s clients to quickly evaluate different medical networks used in their workers compensation programs while delivering significant bottom line savings
• The Network Optimizer is an interactive, prescriptive analytics tool that provides an objective comparison of multiple Preferred Provider Organizations (PPO’s) and Specialty Network Configurations using a clients historical bill data
• Utilizing StrataCare’s Book of Business (BOB) to develop metrics by state, PPO network, provider and specialty class, alternative PPO network mosaics are identified for the client, optimizing PPO savings state by state
• Use of the Network Optimizer by Xerox clients has resulted in an average of 8-10% of additional medical savings
© 2015 StrataCare, A Xerox CompanyAll Rights Reserved.
Diagnostic
Client Database
Mirror
Replication
Network Optimizer
. . .Fraud & Abuse Detection
Network Leakage Detection
Analytics R&D
:
:
C
B
Network Optimizer
15
Production Environment
Client Stewardship & Support
. . . .
Customer Reporting
Client Database
“Production”
Enterprise Data Warehouse
ETLDe-Identification Network Optimizer
Network A
ETLDe-Normalization
Client Database
Mirror
. .
Yesterday: PPO Network Analyst researchdescriptive and interpretive analytics to determine how to achieve outcomes, and updates mosaic
Medical Bills Claims Admin Settings Workflow Rules PPO Network Mosaic
Financial Validation Supply Chain Connectivity
© 2015 StrataCare, A Xerox CompanyAll Rights Reserved.
Prescriptive
Client Database
Mirror
Replication
Network Optimizer
. . .Fraud & Abuse Detection
Network Leakage Detection
Analytics R&D
:
:
C
B
Network Optimizer
16
Production Environment
Client Stewardship & Support
. . . .
Customer Reporting
Client Database
“Production”
Enterprise Data Warehouse
ETLDe-Identification Network Optimizer
Network A
ETLDe-Normalization
Client Database
Mirror
. .
Today: PPO Configuration Administrator leverages results of Network Optimizer and updates mosaic
Medical Bills Claims Admin Settings Workflow Rules PPO Network Mosaic
Financial Validation Supply Chain Connectivity
© 2015 StrataCare, A Xerox CompanyAll Rights Reserved.
Client Database
Mirror
Replication
Network Optimizer
. . .Fraud & Abuse Detection
Network Leakage Detection
Analytics R&D
:
:
B
D
Network Optimizer
17
Production Environment
Client Stewardship & Support
. . . .
Customer Reporting
Client Database
“Production”
Enterprise Data Warehouse
ETLDe-Identification Network Optimizer
Network A
ETLDe-Normalization
Client Database
Mirror
Adaptive Updates
Adaptive
Tomorrow: Mosaic updates are made by the Network Optimizer, automatically and adaptively
Medical Bills Claims Admin Settings Workflow Rules PPO Network Mosaic
Financial Validation Supply Chain Connectivity
© 2015 StrataCare, A Xerox CompanyAll Rights Reserved.
Composable Analytics provides an analytics
platform based on some intuitive data-flow
tools and services
Enterprise Analytics Marketplace
• Platform provides for rapid app authoring and data encapsulation
• Facilitates creation of an enterprise marketplace both data and analytics for consumptions by users and processes
(1) GE Global Software and Analytics Research, W.A. Ruh, M. Grabb
GE’s Global Research labs are establishing
solutions for the prediction and execution of
required maintenance of physical assets
“Digital Twins”
• Leveraging next generation thermodynamic simulations to create a “digital twin” of real physical assets
• These models allow for a view of the asset’s future by observing how its digital twin performs in a wide variety of situations, including where the asset may break for buckle
Optimization and Continuity: GE is focusing on predictive
and adaptive maintenance to eliminate downtime and optimize assets to deliver maximum value over their lifetimes
This is News! – Advancing Adaptive Analytics
Composable Analytics2GE – Predictive Maintenance1
Allows disparate
stakeholders to explore,
discover and leverage
analytical work for application consumption
(2) Composable Analytics – Data Flow Intelligence, January, 2015
18
© 2015 StrataCare, A Xerox CompanyAll Rights Reserved.
Summary – What Are We Doing?
19
Expanding our adaptive platforms
that can readily consume intelligence
Optimize Human Assets
Continued investment in analytical value creation
and harvesting for consumption