Bending Health Care Costs to a More Sustainable Trajectory
The mission of PforP Health is to decrease cost and increase quality in the self-insured healthcare market. By deploying our expertise in healthcare delivery, administration, financing, and regulation, along with our cutting-edge technology platforms, we increase transparency and the control self-insured plans exercise over their expenditures, while improving the well-being of their beneficiaries.
Contact
➤ LOCATION
1680 NJ-23 #250
Wayne, NJ 07470
☎ CONTACT
info@forphealth.com
(917) 921-3063
Areas of Service
Data Warehousing
Healthcare data of self-funded plans exist in multiple, non-standardized formats, including medical claim files, pharmacy claim files, enrollment files, banking records, and others. For plan sponsors tasked with critical decision making, this multiplicity in data sources and formats can hamper comprehensive clinical and financial analysis across the healthcare continuum of their beneficiaries.
PforP solves this problem by extracting, transforming, and loading the various data streams into a centralized Azure database. All data is normalized in the “PforP Common Data Model,” from which meaningful and comprehensive analysis can be made.
The PforP Common Data Model is designed to analyze every healthcare transaction regardless of the originating vendor or the size of the plan.
PforP can ingest bulk batches for retrospective analysis or daily scheduled batches for near real-time, ongoing analysis in a secure environment that is HIPAA and HITRUST compliant.
Predictive Modeling
Machine learning and predictive analysis applied to normalized data sets in the PforP Common Data Model allow plan sponsors to identify opportunities for better financial decision making. This can be particularly useful when benefits design changes are contemplated, or when plan sponsors wish to evaluate the proposals of competing vendors. Social determinants may be studied using predictive modeling to plan educational initiatives. Existing services can be evaluated for their effectiveness or a service can be tailored to the patient population’s needs.
Utilization Analysis
Healthcare financial and clinical records in the PforP Common Data Model contain a vast amount of structured and unstructured data that can be mined for insights to improve quality, reduce costs, and drive resource planning. PforP analytical tools can “hot spot” retrospectively or in real time, identifying anomalous use of the system for targeted interventions.
Care Coordination Programs
Fragmented healthcare delivery can lead to poor health outcomes and increased costs to a plan. This is especially true of the small percentage of a plan’s members that account for the largest proportion of expenditures. PforP can identify these at-risk populations, and intervene at both the patient and provider level to better align resources, close gaps, and increase efficiencies.
Real Time Claims Review
From a fiduciary standpoint, plan sponsors must confirm that a dollar-for-dollar correspondence exists between payments from the plan to its carrier/TPA and from the carrier/TPA to providers. In other words, the carrier/TPA should function as a ‘pass through” for plan assets. Nothing should be retained by the carrier/TPA. Examples of retentions include hidden administrative fees added to health claims, or overpayment recoupments and refunds not returned to the plan.
PforP aggregates claims data from sources independent of carrier/TPA universal claim files, including the Electronic Data Interchange and ACH banking transactions. Analysis of these data allows verification that only the proper amounts are paid by the plan as a result of carrier/TPA claims adjudication.
Parallel Claims Adjudication
Every self-funded plan should monitor its carrier/TPA for the accuracy of claims adjudication. Retrospective audits typically identify a 3%-6% error rate. Unfortunately, these labor-intensive audits discover errors long after they have been made, hindering recoupment.
PforP can ingest enrollment, benefits, and plan design data into its contract management system, and can adjudicate member claims in parallel with the carrier/TPA. This system can automatically verify whether claims are being adjudicated in accordance with plan design and carrier contract, and that benefits are paid only to eligible participants. Errors can be identified in real time, before plan funds are released, avoiding the need for expensive recoupments in the future.
Client Support
PforP assigns a professional Project Manager to each client plan for implementation and customer service. In addition, web-based or in-person tech support and training can be provided. Plan administrators and authorized parties can have 24-hour access to data and reporting via a web-based browser.
“We owe it to taxpayers and to public employees to guarantee that we do not pay a dime more than we should for healthcare costs.”