Healthcare · Analytics
Payer Analytics & Reporting
Overview
Developed the reporting suite that health-plan actuarial, network, and care-management teams run their business on. Member-month calculations — the denominator behind nearly every per-member-per-month (PMPM) metric — were derived from enrollment spans with retroactivity handling, and fed utilization, cost, and premium analyses.
Financial and actuarial reporting included IBNR (incurred but not reported) reserve reports built from claims-lag triangles, and insurance leakage reports quantifying spend that left the contracted network or missed negotiated rates. Clinical and network reporting covered care-gap reports (driven by quality-measure results), claims reports, provider rosters, and provider performance reports comparing cost and utilization against peer benchmarks.
High-cost member reports stratified the population by spend and risk to surface the small share of members driving a disproportionate share of cost — the starting point for case-management intervention. This portfolio of reporting was delivered across engagements with 80+ US healthcare clients, including data from major payers such as Aetna, Anthem, and Blue Cross Blue Shield plans.
Use Cases
Actuarial & financial reporting
Member months, PMPM metrics, and IBNR reserve estimates from claims-lag triangles give actuarial teams the numbers behind pricing and reserving decisions.
Care-gap & quality outreach
Care-gap reports translate quality-measure results into actionable member lists for outreach and intervention programs.
Network & provider insight
Leakage, provider, and provider-performance reports show where spend leaves the network and how providers compare on cost and utilization.
High-cost member management
Spend and risk stratification surfaces the members driving disproportionate cost, prioritizing case-management resources where they matter most.