Unlocking the Power of Claims Data

Four ways to optimize student health insurance plans with claims data

Student health insurance claims data can provide a wealth of knowledge—if you know where to look. Whether you review your claims activity monthly, quarterly, or by semester, the process can allow you to see how the year is progressing and year-over-year performance. Think of it as a student health plan barometer, helping identify any trouble areas that could arise. It can also be used to help you anticipate and prepare for any potential plan increases the following year.

Use these four data points to start making data-informed decisions that can help you optimize your health plan using the claims reports you already receive and put the focus on the well-being of your students.

Are atypically large claims are derailing your plan?

Large claims can and do happen, but they shouldn’t upset an otherwise stable insurance plan. However, they can affect your claims experience.  Large-dollar claims can be considered a normal trend or as an unusual occurrence. If the large-dollar claims are part of a normal trend, then they will be factored into your insurance rate going forward.

If they are considered atypical, nonrecurring large insurance charges—such as an acute condition resulting in a lengthy inpatient stay or a complex surgery—they should be separated and pooled with your carrier’s portfolio of other large claims. If you discover a large atypical claim, ask your broker or carrier if that charge is being removed from the completion factor or how it is being discounted from the experience. Familiarizing yourself with your claims trends will help you identify anomalies within your student health plan as they occur, and potentially save you from a higher premium during your renewal negotiations. Try requesting bi-monthly reports from your broker or carrier, so you can catch those large claims as they happen.

Are students seeking care where you want them to?

Because network providers are typically more cost-effective for both the insured student and the plan, in-network care, as opposed to out-of-network care, is the preferred option.  A claims report can uncover behaviors that drive up plan costs such as the number of student health care services being provided in-network.  Armed with this data, you can compare current student activity to your school’s goals and evaluate whether or not there is a need to drive student behavior.

Find the total allocation for in-network versus out-of-network services section of your claims reports.  Because large claims amounts can have an outsized effect, allocation data alone doesn’t tell the whole story. Examine allocation amounts in conjunction with the specific numbers of in-network and out-of-network claims to monitor out-of-network provider usage, and create on-campus student outreach strategies before those expensive out-of-network visits get out of hand.  If you find that 85 percent of payment allocations are in network, but only 50 percent of all total claims are filed in network it might be time to increase awareness of health care options on campus.

Is the student health center being accessed enough?

A health care center can be a vital part of your student health plan and have a significant effect on costs, so you’ll likely want to try to promote its usage and leverage it as a cost-effective care provider. You can use claims data to help diagnose specific campus needs such as an increased emphasis on wellness, greater mental health assistance, or more education on how students can obtain insurance.

Start by using it to tell you how many students are visiting the student health center for care and how often are they going. Then use it to surface the services students seek most frequently and if certain services offered by the student health center are being underutilized. If students are going straight to a doctor’s office or urgent care for minor ailments like sprains or sinus infections, it may be worth educating your student population about the resources that are offered at the student health center via email campaigns and on-campus materials.

Is there excessive emergency room use?

Your claims report can also reveal if your students are making too many trips to the emergency room—a common problem, especially within international student populations who are unfamiliar with alternative health care options. An average ER visit can often lead to claims exceeding $2,000, proving costly for both students and health plans.

Use emergency room claims data from previous years or, if available, other schools, to provide a valuable frame of reference. Consult with your broker or carrier to determine how your school’s emergency room claim amounts compare to claims from other providers during the same period.

Check to make sure you understand what practices your plan’s claims administrator has in place to obtain proper discounts, adjudicate claims that may arise from non-emergency care, and remove unreasonable charges (whether or not they are emergency room claims).

Reviewing claims data before your annual policy renewal date can help pinpoint activities, utilization behaviors, or trends that will influence important decisions about your plan, such as the changing of a benefit offering or the incorporation of a different network.

If diving into data analysis seems daunting, there’s good news—you’re not alone. Your broker or health plan provider can be a valuable partner in the process by regularly reviewing claims data with you and conveying what that data means for your program.

Schedule a claims data review to more fully evaluate the intricacies of your institution’s student health insurance plan and manage it more strategically and sustainably.

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