Healthcare / Insurance

With global concerns about containing the cost of health care, discussions in many countries about how best to care for an aging population and the ongoing debate in the US on health system reform, it’s clear that those health care organizations that can adapt swiftly and strategically to changing dynamics will be better prepared to succeed long-term. There has never been a greater need to derive trusted insights from data, and the use of advanced analytics is critical.

More than 500 US hospitals use SAS software to improve their quality of care, productivity and patient/staff relation to enable better and more informed decisions and to drive their organizations forward.

Only SAS addresses the entire process of translating raw data into useful, trusted and timely information for evidence-based decisions. Only SAS allows you to:

Patient Safety and Quality of Care

•  Identify best practices by measuring performance against benchmarks.
• Drive evidence-based practice by sharing information at the point of service.
• Optimize outcomes by understanding the cause-and-effect relationships between performance metrics.

Financial/Operational Performance

• Control rising costs, respond to increasing regulatory and consumer scrutiny, and implement initiatives such as pay-for-performance.
• Adapt easily to new business models.
• Identify strategies to address revenue cycle and performance management issues.
• Maximize allocation of scarce resources, and eliminate waste and duplication of effort by analyzing operational data.
• Enhance communication and collaboration across the delivery system.

Integration of Clinical and Business Information for Evidence-Based Management:

• Measure, monitor and evaluate performance relative to employee and physician retention, internal operations and clinical care, growth in market share, revenue growth and productivity enhancement.
• Connect revenue and profits with intangible measures such as patient, employee and physician satisfaction by integrating data from disparate systems.

Financial Intelligence:

Qualex’s solution facilitates regulatory compliance by integrating data management and financial intelligence with the finest online analytic processing in the industry. It allows you to view your institution from any perspective: facility, line-of-business, departmental or others.

With SAS Financial Management, healthcare financial leaders can collate financial information from a variety of systems across their organization, yielding timely and comprehensive results. Our solution facilitates regulatory compliance by integrating data management and financial intelligence with the finest online analytic processing in the industry. It allows you to view your institution from any perspective: facility, line-of-business, departmental or others.

SAS Financial Management includes two integrated functional components:

• Planning allows finance executives and other relevant finance department personnel to embed advanced SAS analytics into budgets and plans to forecast future operating results more accurately.
• Financial reporting consolidates multidimensional information on demand while performing all financial calculations relevant to the reporting and planning processes, thereby enabling organizations to close their books more rapidly.

Benefits of financial management With SAS Financial Management, financial officers and other healthcare leaders will benefit from:

• Timely and accurate forecasts Develop accurate plans and forecasts that can be updated easily in response to changing business and operational circumstances.
• Greater financial transparency Create a more transparent environment for managing financial and operational data to produce timely, accurate and relevant reports. This transparency is achieved by extending control of information horizontally across the institution and vertically between transaction-oriented systems and the higher-level financial management system.
• Rapid report publishing Reduce the time required to produce and publish financial reports. On-demand consolidations, which simultaneously incorporate any necessary currency conversions, eliminations, ownership adjustments and allocations, can reduce the time and cost of financial consolidations.
• The integrity of financial information Maintain data integrity and security through the financial data mart that protects the data that supports intelligent decisions. Consolidate financial data from diverse sources systematically to avoid manualthus error-pronetranscription.
• Financial performance management Integrate performance management systems, such as scorecarding, financial consolidation, analysis and reporting, and budgeting.

Human Capital Management:

This solution can provide healthcare HR professionals with an overall view of their organization as well as help them integrate diverse data and enable them to make decisions that align with organizational goals. SAS Human Capital Management equips you to:

• Integrate the disparate HR data sources needed for workforce planning to provide analysis of demographics, diversity, age and critical skills.
• Track investments in human capital by monitoring internal courses and rewards.
• Recruit for hard-to-fill positions by incorporating data from the Bureau of Labor Statistics and Integrated Postsecondary Education Systems (IPEDS).
• Measure strategy against key performance indicators.

SAS also can help you accomplish such workplace planning goals as:

• Strategic planning.
• Recruitment and retention.
• Human capital development.
• HR performance management.

Intelligence Platform:

Many hospitals are faced with a daunting amount of data, many in separate systems. Qualex can help you bringing information from all these systems together into one comprehensive view that puts administrators, physicians and staff on the same page.

IT Management:

Using Qualex’s expertise, IT executives can better manage their IT infrastructure, as well as evaluate, control and report costs. Qualex’s healthcare solutions also provide evidence-based intelligence to executives, financial leaders and business managers to help communicate their IT’s performance and strategic role.

With SAS IT Intelligence, your IT organization can address key questions, such as:

• Are we using technologies already in place?
• What are the costs for IT-delivered services and products, and where are those products and services being used?
• Are IT products and services distributed appropriately based on organizational goals and priorities?
• Why is client/server costing so much when individual expenses seem small?
• Are my service levels satisfactory?

Using SAS IT Intelligence, IT executives can manage and communicate performance; assign costs using factors such as consumption metrics, service usage and capital expenditures; and do trend analysis to help communicate IT’s performance and strategic role.

Performance Management:

Implementing SAS statistical capabilities with SAS data access and reporting capabilities, Qualex helps leaders of hospital and healthcare systems improve business management.

SAS Performance Management enables you to focus, communicate and collaborate on strategy from a single portal. With SAS Performance Management, you can balance business goals with quality clinical outcomes and align the objectives of administrators and clinicians.

No matter which performance management philosophy you embrace Balanced Scorecard, EFQM, Baldrige or Six Sigma SAS Performance Management supports it. SAS helps you integrate, distribute and analyze organizational and clinical information identifying best practices for success and opportunities for improvement so you can act on it swiftly and appropriately.

SAS Performance Management exchanges information with other business solutions across your organization solutions for managing customer and supplier relationships, IT, finances, and human capital to ensure everyone is working in sync and heading toward common goals. The result? A steady finger on the pulse of all measures that add real value to your enterprise.

Procurement Management:

Through an integrated set of data management and analytic applications that work with existing operational data and systems to gather, Qualex can help you analyze and leverage all aspects of supplier data and purchasing history, thereby optimizing strategic sourcing and achieving significant cost savings.

Consisting of four fully integrated components, SAS Supplier Relationship Management allows you to maintain the flexibility you need to focus on your greatest pain today and then expand into other areas of improvement:

SAS Sourcing Data Quality provides accurate, detailed, comprehensive information to help you reduce commodity spend without increasing risk. SAS uses repeatable, automated coding based on industry standards and can readily accept any classification system. With SAS you can:

1. Normalize your supplier information for more accurate measurement.
2. Leverage third-party information for supplier enrichment.
3. Ensure that your suppliers are accurately and consistently named. SAS Spend Analysis helps you reduce enterprise spend across suppliers and commodities by increasing the visibility of procurement information. With it, you can:
   • Leverage institutional buying power for cost-savings.
   • Identify ways to buy more effectively from valued suppliers.
   • Perform weighted supplier ranking using the criteria most important to you to evaluate which suppliers are best suited to serving your institutions needs SAS Procurement Scorecard helps you set, measure and manage procurement strategies that are aligned with goals based on information from all of the procurement systems throughout your institution. With it, you can:
     1. Create and maintain scorecards for individual suppliers and the entire procurement organization.
     2. Measure performance against procurement-specific KPIs.
     3. Reduce total spend and supplier risk.
     4. Ensure supplier quality, on-time delivery and performance.
4. SAS Sourcing Strategy uses operations research techniques to add balance and flexibility to the supplier evaluation process. It employs user-defined business rules, so you can:
   • Narrow your list of suppliers.
   • Recommend how much to spend with each supplier to achieve your procurement goals most effectively.

Insurance relies on the ability to predict future claims or loss exposure based on historical information and experience. However, insurers face an uncertain future as they face spiraling operational costs, escalating regulatory pressures, increasing competition and rising claim expenses. With more than seven years of experience in the insurance industry, Qualex can help you achieve long-term success and obtain peace of mind. Integrated and extensible insurance solutions built on a flexible business analytics framework and insurance-specific data model speed up both implementation and results, giving you a fast track to significant ROI.

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.

To ensure long-term survival and success, insurers must not only keep their customers happy but also remain profitable in an ever changing industry. Qualex can help deliver peace of mind to insurers by managing risk, increasing customer profitability and improving operational efficiency in the following ways:

Claims Fraud Management:

With insurance claims fraud becoming more widespread and particularly attractive to organized crime syndicates, insurers are in need of fraud detection more than ever. Our solutions can help you uncover fraudulent claims that previously went undetected as well as aid in the prioritization of fraudulent claims and reduce false positives, among other things.

Cross-Sell/Up-Sell:

Despite its importance, many insurance companies struggle to perform effective cross-selling. Market basket analysis uses historical data on policies held by clients as well as details of active policies, customer demographics, claims propensity and other key variables to predict cross-sell opportunities.

Customer Retention:

Our solutions allow insurers to use the customer data they gather from all corners of their enterprise to calculate a customer’s likelihood to have a specific policy lapse. Marketers can use these “likelihood” scores, in combination with customer profitability information, to segment the existing customer base and effectively target valuable customers to prevent further attrition.

Customer Segmentation:

Our solutions give insurers access to the analytical depth of SAS to help marketers create more accurate customer segments and predict customer behavior, which in turn gives insurers the power to create better-targeted product offers, product communications and bundled services.

Performance Management:

With the broadest, deepest range of offerings for performance management available, Qualex helps financial institutions increase revenues, manage risk, reduce costs and bring context and direction to your business intelligence initiatives.

Risk Management:

Enterprise risk management delivers a current, credible understanding of the risks unique to your organization across a broad spectrum that includes all types of risk.

Disease Management:

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:

1. 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.

2. Identification and Severity Classification:

   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.

3. 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.

4. Outcome Management:

   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

Fraud:

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:

1. 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.

2. 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.

3. 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.

4. Health Plan Reporting

   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:

• uperior 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.