Insurance Claims Analytics Solution

Insurance analytics in healthcare investigates the insurance claims data including the validity of submitted claims and determines the extent of the coverage it warrants. Analyzing claims is one of the most important activities for payers and consumes most of the resources. It is necessary to detect faulty and fraudulent claims and prevent losses for payers. Studies and research have revealed that inaccurate claims waste nearly $17 billion for payers every year. Analytics in insurance claims help payers filter out faulty or inaccurate claims and improve their revenues.   

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Explore Insurance Claim Analytics

Medical claim analytics involves tonnes of paperwork and back-to-back communication. As a result, data analytics in the insurance sector and the diagnosis of claim outcomes can slow down. Predictive analysis can perform health claim analytics and identify claims having the potential for high-defense costs. Predictive analytics in insurance combined with health claim analytics can simplify insurance claims data processing.

 OSP can create predictive analytics in insurance analytics that would facilitate real-time sharing updates of claims. Our customized insurance analytics assess claims before sending them to the payer companies. We can help you predict the possibility of claim approval against the actual value claimed. Our custom predictive modeling compares factors associated with new and pending claims with those of past losses. In this way, testing historical claims data from diverse insurance provider companies produce an algorithm that predicts the possible claim approval value. OSP’s insurance claims data analytics yield accurate statistics of the generated claims that further assist the traders in decision-making. 

The Health Insurance industry in the USA is expanding with different types of policies being offered to patients. Health insurance fraud is a major crime in the USA, which could have severe consequences. A health insurance fraud refers to a situation where an insured or medical service provider produces fraud, false or misleading information to the insurer to obtain benefits from a policyholder’s policy.

OSP can develop insurance analytics integrated with claim fraud analytics solutions for identifying fraudsters and their intention of inflating claims for personal benefits. Our custom insurance analytics solutions can predict potential fraud through a fraud detection algorithm, so necessary actions can be taken on time. We can streamline the process of fraud detection and provide risk alerts, thereby improving claim analytics in insurance. OSP can mitigate fraud detection challenges and help insurance companies in the US address concerns of fraud claims.

The loss ratio in terms of claim analytics in insurance is a percentage that represents the ratio of losses incurred in claims and adjustment expenses relative to the premiums earned during the period. There are two main types of loss ratios in medical claim analytics: medical loss and commercial insurance loss ratios. The medical loss ratio means the ratio of healthcare claims paid to the premiums received. A commercial insurance loss ratio is meant for the insured, where the insured needs to maintain an adequate loss ratio, or else it costs a non-renewal of insurance or increased premium for the cover. 

OSP offers a wide range of healthcare business solutions, including insurance claims data processing. We can create insurance analytics to help calculate the losses incurred in claims. Insurance companies can estimate the losses or potential losses in their policies using our custom medical claim analytics. This will allow insurance providers to be in a better position of self-assessment. Based on the loss ratio analysis using OSP’s health insurance claims software, insurance companies can decide the premium cover costs. 

Medical insurance claim companies have their data, policies, terms, conditions, market trends, and so on. If all this data is isolated within each company, each carrier can only view its portfolio. On the other hand, when carriers analyze market data, they can view their business concerning the market and gain new insights that earlier seemed impossible. A contributory database in insurance analytics means collecting health informatics supplied by insurance market members to a central repository that gets shared between the contributors. 

OSP can develop health insurance analytics with a contributory database that would add value to insurance companies by normalizing, standardizing, aggregating, and linking the market-contributed data with other information. In this way, carriers would derive revue growth and profitability, improve operational efficiency, come up with new concepts, and protect themselves against fraud. OSP’s customized claims data analysis can establish contributory databases that enhance insurance companies’ success and growth.

Telematics in insurance analytics are methods for collecting information or data to offer personal feedback or cost savings on insurance policies. It provides rich data to support insurance companies in the medical insurance claim process or take the required actions. Insurance analytics software incorporating telematics can help fasten the processing of insurance claims, which is especially useful in emergencies that can save hundreds or even thousands of lives each year.  

OSP’s customized health insurance claims management software with telematics can give valuable insights and data on customers. Our claims analytics software with telematics consists of wireless communication, GPS, and other diagnostics that can help with real-time tracking of traffic conditions, risks, customer behavior, and lifestyle. We can develop insurance claims analytics software solutions integrating telematics to help insurance companies in the USA achieve better customer outcomes and improved operational efficiency. Insurance providers can also obtain an increase in revenue through OSP’s insurance claim data software. 

Insurance companies in the USA resort to data management to handle risks, build trust, and empower learning. Health insurance analytics is prone to face changes and sudden difficulties. Healthcare claims analytics can deal with such challenging situations through interactive dashboards.

 OSP can create insurance claim analytics solutions that can facilitate digital transformation and data-driven works to improve operations, customer experiences, and risk management. Our custom insurance analytics allows insurance providers to use data in ways that support better claim management, fraud detection, and lead to increased customer satisfaction. Insurance companies can visualize all data analyzed and prepare reports easily using analytics for insurance designed by OSP. These would enable the companies in quick decision-making.


Fraudulent claims cost billions of dollars for insurance payers. But OSP can develop solutions for claims analytics in insurance to enable payers to place the right filters against their plans for identifying anomalies. Our solution will automate large parts of the assessment process to empower payers to analyze more claims faster and more efficiently. This will increase the number of fraudulent claims detected and save precious revenues for insurance payers.

OPS will build solutions for insurance claim analytics to enable payers to gather information about health plans and claims to determine risks better. Knowing the pattern of risks helps payers to create and modify health plans accordingly and streamline the entire process around claims and reimbursements. Knowing who might require what coverage based on relevant risk factors helps payers prevent excessive reimbursements and better control care costs.

Fraudsters are always looking for newer ways to game the system and get away with as much as possible. We can offer claim analytics to help insurance payers gather operational data on the claims they receive and assess the same to find anomalies. Subsequently, the insights gained from this enable payers to broaden the scope of their claim analytics and stay vigilant of newer tactics that might be used to obtain higher reimbursements.

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Software for Analytics in Insurance


Development of Software Solutions for Claim Analytics

  • Automation of parts or whole of the claims adjudication workflows
  • A dashboard that aggregates all the information on approved, denied, and rejected claims
  • Notification in case a claim deviates from established baselines of normalcy
  • Insights about patterns in claims to help payers modify health plans
  • Identification of potentially fraudulent claims

Customized Software for Analytics in Insurance

  • Thoroughly tested for ensuring compliance with HIPAA regulations
  • Centralized storage and management of confidential of documents
  • Detailed reporting after cutting-edge analytics
  • Risk assessments based on pre-established criteria
  • Automation of claims management processes

Design and Development of Software for Health Insurance Analytics

  • Function for task management to streamline everyday operations
  • A consolidated operations dashboard to monitor performance
  • Interactive UI/UX for impactful user experience and adaptability
  • Features for processing payments done through various means
  • Case management functions to handle denial challenges

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Frequently Asked Questions

Claims analytics is the assessment of data from medical claims to identify useful insights. These insights enable insurance payers to optimize their operations and serve their stakeholders better.

Data about operations contains useful patterns and insights that reveal more about how the industry works. Evaluating risks, determining the treatment cost of chronic diseases, coverage through health plans, deciding premiums, and other vital decisions can be taken accurately by analysing long-term data from claims. This assessment helps payer companies to serve their stakeholders better through informed decisions.

In other words, data analytics is used to make better decisions and derive value for patients, providers, and payers.

     1. Nature of claims – Medical claims can be for any one of the large number of medical services rendered by providers. It is important to factor this in when collecting claims data for analytics, as two or more claims even for the same disease may vary vastly.

     2. Time – Depending on the nature of claims, they can take anywhere from a few days, some weeks, or even a couple of months to process. So it is important to glean usable data after processing has been concluded.

     3. Data Integrity – The claims need to adhere to policies and follow the required regulations, be in the right format, and remain consistent with standards. This ensures that its assessment will reveal actionable insights.

     4. Establish Parameters – Analyzing claims data would need to be done according to some parameters, which means that the objectives need to be clear. These can include assessing spending patterns, treatment patterns, frequency of admissions for particular diseases, and so forth. Data from numerous claims can shed light on these factors.

  • After a person concludes his or her clinic visit, the provider’s side prepares the claims to be sent as bill to the insurance payer. This doesn’t include the out-of-pocket payments made by the patients.
  • The payer adjudicates the claim, checking for accuracy, coverage of services, compliance, and so on.
  • Depending on the health plan, the payer will cover the entire cost, or a part of the cost of the medical services. In case of the latter, the patients pay the remaining cost.
  • If the payer discovers any problems with the claims, then the payer would deny or reject the claim, depending on the extent of the problem.
  • Additionally, the payers send over an EOB (Explanation of Benefits) statement.

     1. Cashless Claim

This is type of medical insurance claim where patients can receive treatment at a network hospital without paying out of their pocket. The claims are sent from the hospital to the payer, who pays it. The patients need to go to a hospital or clinic within the network and show the health plan card with a proof of identification.

     2. Reimbursement Claim

In this type of claim, the patient could visit any medical center, which may or may not be in the payer’s network. After the medical services have been rendered, the patient pays out of his or her pocket and applies for a reimbursement from the insurance company. This could take longer as the patient’s bills, prescriptions, and other relevant documents need to be processed before the claim.

A claim is a bill sent by providers to insurance payers for medical services rendered to patients. It contains details of all the billable services that the providers provide.

A reimbursement is the payment made to providers by payers for the services provided to patients. The payment is based on multiple factors and so, the payers first process each medical claim to test its validity. If everything is found to be proper and compliant, the payers will reimburse the full or partial amount, depending on the health plan.

    1. Reduction in Claims Fraud

This is one of the biggest advantages of claim analytics. Research and studies estimate that claims fraud costs billions to the healthcare industry. So, analyzing claims to identify anomalies or discrepancies helps payers prevent fraudulent claims from being accepted. The more the analytics software assesses such claims, the better it gets with time.

    2. Reliable Risk Assessment

Identifying risk accurately is vital for payers as they can charge the premiums accordingly. This enables them to provide coverage for the members enrolled in their plans. Members who are likely to incur high healthcare costs are deemed higher-risk and so, would be charged higher premiums.

    3. Improve Decision-Making

Assessing insurance claims provides fascinating insights about various factors in the healthcare industry. Things like spending patterns, medical services for conditions, frequency of clinical visits for diseases, and others are identifiable with claim analytics. Insights surrounding these factors, along with other, help payers make informed decisions.

    4. Improved Revenues

Analyzing claims sheds light on risk, reimbursements, claims, and other operational workflows. This insight helps payers identify pain points in their organization and take steps to address them. Subsequently, this results in improved efficiency, lowered overhead, and reduced losses due to fraud. These benefits ultimately culminate in higher revenues overall.

When a patient goes to a doctor, the doctor attends to the patient and provides the necessary services in the form of tests, consultations, prescriptions, etc. The provider then proceeds to code these services to generate a claim to be sent to a payer. The claim is a summary of all the billable services rendered to the patient.

The payer assess this claim, verifies if the services were valid, and provides payment to the provider in the form of reimbursement. This payment depends on the coverage of the health plan. The payer also sends over an Explanation of Benefits (EOB) statement detailing the reimbursement provided corresponding to the services.

Claims adjudication in insurance is the process where the insurance company processes a claim to see if it is valid. If the claim is found to be valid, the insurance payer proceeds to settle the claim, or pay the entity that sent over the claim. However, if there are problems discovered with the claim during the adjudication, the claim is either denied or rejected depending on the situation.

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