How insurance professionals conquer data overload and the decision-making challenge to meet clinical and financial goals

Insurance professionals at every level face mountains of data to sift through to aid decision making. From the claims professional to insurance executives, the quantity of data to evaluate can be overwhelming and intimidating. 

Claims managers wonder if their decisions will effectively influence claimant safety and cost-saving goals. Executives question their course while navigating the book of business toward positive clinical and financial objectives.

Insurance clients say these concerns weigh on their minds:

• Missing an important piece of information
• Not seeing escalating risk until it’s too late
• Making a clinically-sound and cost-conscious decision
• Keeping up with the ever-changing landscape of regulations and clinical guidelines
• Straddling multiple systems to get a full view of the claim

Taking the guesswork out of risk management
Adjusters and executives want to feel confident in their decisions, so it’s not surprising their top three concerns center on the ability to accurately assess risk. Claims managers deal with so many factors, inputs, alerts and information, it’s difficult to hone in on key areas of risk and focus on what’s important.

The Optum VitalPoint® claims portal is designed to highlight areas of current or trending risk. It identifies the most important areas of focus ― whether at the claim level or entire program level ― so that adjusters, clinicians or executives can focus on what’s important to them.

Analyzing 200 million claims’ views to guide appropriate decisions
Engaging the right resource to take action on a claim helps to ensure that focus is where it should be. And limiting the choices a decision maker can choose relieves the decision burden on adjusters. Claims routing and decision enforcement rules are determined by analyzing many sources of data including information about the prescriber, state of jurisdiction, injury phases, spend thresholds, morphine equivalency, opioid and poly-pharmacy prescriptions, etc.

In fact, there are 200 million different permutations from which VitalPoint takes data about a claim to determine who it should be routed to and what decision options are appropriate to align with clinical guidelines, regulatory compliance and cost-containment goals.

This comprehensive data analysis allows adjusters to be responsive to the needs of the injured individual while at the same time select from lower cost, highly-effective alternative medications — which have proven to deliver 97.5% generic efficiency — to achieve clients’ financial objectives.

Risk assessment - identify, assess, combat, and monitor for success
Call-to-action tools visualize where treatment and spend risk exist with a claim or set of claims to pinpoint where to focus attention. The view includes:

• Risk – the check engine light: The current risk score aggregates medical, clinical, financial and fraud risk factors into an easy to understand metric for all claim professionals. Risk is evaluated within the claim ecosystem — relating and measuring against other claims — providing a view to the health of the claim and what’s driving escalated risk over time.
• Risk matrix – the needle in the haystack: Risk is measured across the book of business according to different risk metrics, and riskier claims are isolated. The claims professional can quickly distinguish the less critical claims and focus attention on managing the higher risk claims.
• Risk action plan – the needle is found; now what? Excessive case load, or inheriting legacy claims (already in critical status) may cause claims to leak into a riskier status. VitalPoint risk identification alert programs, fueled by Optum’s extensive experience, bring attention to potential problem claims and recommend proven intervention strategies.
• Risk improvement monitoring – are my actions making a difference? The dashboard displays changes in risk assessment as intervention programs are initiated — signaling success or whether to pivot to new strategies.

Client favorite VitalPoint Express® saves time with email access and no log-in required
Anytime a risk or issue is identified, the claims professional is alerted via email using the interactive email technology — VitalPoint Express. This productivity-enhancing tool allows adjusters to quickly and easily review and process pending claims via secure email. VitalPoint Express users have access to the necessary suite of functions and claim reporting to render an informed decision without having to log in into the VitalPoint portal and without sacrificing security.

A 25% boost in decision request resolution from VitalPoint Express
Clients who take advantage of VitalPoint Express see decision requests resolved within the first day ― 25% more often than clients who do not subscribe to VitalPoint Express.

Rapid response from client support associates, when needed
The self-service capabilities of VitalPoint Express allow the majority of claims processing to be completed independently by adjusters. This frees up client support associates to focus on more complex claims and handle 80% of pharmacy calls in 30 seconds or less.

Client users with a state fund say that email notifications from VitalPoint Express save a lot of time and avoid phone tag. 

Clients praise the simple navigation and ease-of-use in VitalPoint

“I love to toggle between systems” — said no one ever
In addition to the fast and easy access provided by VitalPoint Express, the portal simplifies workflow through single-sign on capabilities that connect Optum with clients, enabling insurance professionals to effortlessly obtain claim information. Single-sign on between client source systems and VitalPoint data integration services eliminates unnecessary workflow steps, allowing users to process transactions from their internal claim management systems — no need to straddle multiple systems.

Users with a large Midwestern insurance company say VitalPoint is one of the best portals they use, and they use a lot of portals. They state that it’s easy to navigate, visually appealing and user friendly. These users add that VitalPoint efficiently manages their claims, and they really like all the resources available at their fingertips.

Total Care Management
VitalPoint aggregates data from pharmacy, ancillary and medical services and synthesizes it through claim management tools to manage a claim from the first report of injury to claim resolution and anything in between. When someone is injured, they rarely just need a prescription as their only treatment. Often, they need crutches, a hospital visit, additional physical therapy, a visit to a specialist, and possibly even modifications to their home or workplace.

Synthesizing data across the entire claim spectrum allows a holistic view of the injured person’s treatment. Optum’s Total Care Management program removes the complexity from managing the medical treatment of claims and provides easy-to-use insights to help ensure claimants get the right treatment at the right time, for the right duration, and at the right cost.

The VitalPoint portal is a one-stop-shop for seamless integration of Optum lines of business. Packaged in a simple to follow user experience and powered by Optum data analytics, payers, TPAs and self-insured entities have access to the tools necessary to support the management of care, without having to bear the capital investment to fund and maintain their own system to do this.

What’s next?
Optum will continue to enhance workflow efficiencies and the user experience, incorporating artificial intelligence and machine learning, to fuel advanced analytics delivering optimum insights. The goal is to provide a comprehensive, all-in-one solution enabling insurance professionals to reach clinical and financial goals and improve the lives of claimants.