Plan Modeling

The effect a particular plan modification will have on member disruption and a plan's bottom line is notoriously difficult to calculate. Basic plan settings such as deductible / co-pay amounts and coinsurance percentages all have a compounding effect on dollars paid by sponsor and member. Out-of-pocket maximums, benefit level maximums, and custom adjudication rules only add to the complexity.

Planwatch includes an innovative plan modeler and basic claim readjudication engine that make it possible to ask various types of What If? questions about how claims would have been paid differently given a modified design.

Adjudication engine

Historical claims data is fed into the readjudication engine along with a modified plan design. The engine readjudicates each claim with the modified plan settings member-by-member, charge-by-charge. The resulting simulated claims data is then compared to the actual claims data providing a proven method for evaluating overall impact and member disruption.

Plan Model Settings

The Plan Modeler allows many aspects of sponsor and member contribution to be customized:

  • Single and family deductible amounts for network and non-network activity.
  • Deductible network integration controls whether network and non-network deductibles are reached separately or combined.
  • Dependent age limits.
  • Single and family coinsurance percentages for network and non-network activity.
  • Single and family out of pocket maximums for network and non-network activity.
  • Coinsurance network integration.
  • Per benefit adjudication rules and amounts.
  • Sponsor contribution maximums can be set on a per benefit level based on dollars, number of visits, number of days, or number of incidents.

Take a tour of the Plan Modeler settings screens

Comparison and Disruption Analysis

After a Plan Model's claims are readjudicated, the simulated claims activity is analyzed and compared with historical claims activity to produce three reports:

  • Overall Comparison Analysis - provides a high level overview of change between the actual claims activity and modeled claims activity. This includes deductible, copay, coinsurance, ineligible charges, and plan contributions.

  • Benefit Comparison Analysis - shows the amount of change between actual and modeled plan broken down by benefit category.

  • Member Disruption Analysis - determine which members are likely to be impacted by the simulated changes and by how much.

Take a tour of the Plan Modeler comparison reports