Services performed
- Bespoke clinical grouper
- Case-mix adjustment for fair comparison of healthcare facilities and providers
- Interactive dashboards summarising provider services for decision-support
- Outlier hospital event detection
Client
Liberty Health provides health insurance to clients across 27 countries in Africa.
Challenges
The health insurance industry in Africa is challenged by paper healthcare claims, a lack of standardised coding and tariff systems, and limited regulation of providers and hospitals – which make tasks such as pricing, fraud detection and provider network selection difficult.
Our solution
We used available information on providers, including an analysis of their claims history and text mining techniques, to construct a practice discipline mapping to better describe the clinical services rendered by different providers. An algorithm-based classification system that captured the range of services provided by a particular healthcare provider was built for the client. A bespoke clinical grouper was developed and implemented that allowed the client to perform case-mix adjustment of hospital admissions, providing insights into the nature of services provided and costs relative to other providers in the country. This has been critical for the selection of providers for networks offered by the client, due to the need to balance both tariff levels and appropriate access to care.
