By Diana Garber
In order to rapidly identify patients with treatable illnessesand reduce the administrative costs related to providing services to these customersBlue Cross and Blue Shield of North Carolina (BCBSNC, Durham, NC) and BioSignia Inc. (Durham) are co-developing a software program that will review insurance claims using predictive modeling technology.
The program, designed by BioSignia, is being created to identify candidates for BCBSNC's free healthcare management programs. BCBSNC, which is implementing this program in order control expenses, takes patient lists complied by the program and alerts the people on the lists of the availability of existing health management programs.
The basis for the predictive modeling program is an algorithm. The program scans claims filed with BCBSNC and records the dollar amounts, diagnosis and procedure codes. The program has 159 distinguishable diseases in its memory. The program then ranks how far the disease has progressed and how treatable and/or preventable it is in its current stage. The system is looking to pinpoint complicated but treatable conditions. If a patient has a medical condition listed as treatable and resource consuming, the patient is considered a prime target for BCBSNC's healthcare management programs. Once these patients are identified, a nurse from the insurance company contacts the patient and discusses the medical treatment the patient is receiving and if any changes should be made.
According to Stephen Blackwelder, Ph.D., manager of quality improvement research and biostatistical support of BCBSNC, "the goal of this program is to identify and act more quickly on behalf of members who are in the midst of complicated medical situations. By running the claims through this algorithm, we are hoping to identify people in these situations rapidly, and then implement the solutions we already have in place more quickly."
BCBSNC will look at the diagnosis on the claim and how much the procedure cost, not the customer's name on the claim. Patient participation in any of the programs is purely optional and will have no impact on premium rates, according to the insurer.
Currently the only way for BCBSNC to get patients to use any of its health management programs is by a doctor's referral, or if a patient decides to call the insurance company's 1-800 number. BCBSNC is hoping to reach a broader audience through the new program. "Potentially, we want to improve quality of the situation customers are experiencing and keep the cost down for the employer and for us," Blackwelder adds.
BioSignia, which had developed the software before signing the agreement with BCBSNC, is still refining the system. Although so far it has only licensed the software to BCBSNC, the vendor thinks the program could be beneficial to many companies. According to Guizhou Hu, Ph.D., vice president of research and development at BioSignia, "They can use this system to identify the people to whom they can provide a health promotion to help review medical costs. We want to make this a product that can be available to many other managed care companies."