System and method for using financial incentives with member engagement metrics to reduce health care claim costs

Abstract

A health care plan system and method designed to reduce future claims costs through financial incentives with member engagement metrics. Targets are pre-set for member engagement metrics. Claims cost targets for the sponsor are set based on the sponsor meeting member engagement targets. A percentage of health care plan base administrative fees are at risk based on the sponsor's claims cost performance in relation to the claims cost target. If the claims cost target is missed, the health plan administrator repays or reduces administrative fees charged to the sponsor. If the claims cost target is met, the sponsor pays additional fees to the health plan administrator. Base administrative fees are also repaid or reduced if the health care plan administrator fails to meet service performance targets. The sponsor is appraised on progress of member engagement and service performance metrics through scorecards that are sent during the plan year.

1 . A computerized method for determining health care administration costs comprising:
 (a) receiving at a server:
 (i) administrative fee data comprising at least one administrative fee charged by a health care plan administrator to a sponsor of a health care plan for a plurality of members of a member population; 
 (ii) plan activity data for at least one plan activity requiring participation from said plurality of members; 
 (iii) a target participation level by said plurality of members in said plan activity; 
   (b) receiving at said server a participation number indicative of members in said health care plan participating in said plan activity;   (c) comparing by said server said participation number to a member population number to calculate an actual participation level for said member population;   (d) calculating by said server a difference between said actual participation level and said target participation level;   (e) calculating by said server a claims cost target for said sponsor according to said difference between said actual participation level and said target participation level wherein said claims cost target is a cap on claims cost growth during an applicable health care plan period;   (f) measuring at said server actual claims cost performance against said claims cost target for said applicable health care plan period to determine a claims cost difference for said member population;   (g) calculating at said server an administrative fee for said health plan administrator based on said claims cost difference for said member population;   (h) adjusting an administrative fee to be paid by a sponsor according to said members' progress toward said target participation level for said plan activity; and   (i) generating a claims cost scorecard comprised of a first column indicating a predetermined weight to be given said plan activity, a second column indicating said target participation level for said plan activity, a third column indicating said actual participation level for said plan activity, and a participation score.   
     
     
         2 . The computerized method of  claim 1  wherein said plan activity is selected from the group consisting of providing a valid telephone number, completing a health assessment, participating in a health care program, and participating in a pharmacy cost reduction plan. 
     
     
         3 . The computerized method of  claim 2  wherein participating in a health care program comprising participating in a clinical program. 
     
     
         4 . The computerized method of  claim 3  wherein participating in a clinical program comprises participating in a clinical program for disease management. 
     
     
         5 . The computerized method of  claim 1  wherein calculating said administrative fee according to said actual claims cost performance comprises calculating a refund amount for said sponsor if said claims cost difference is greater than a specified percentage. 
     
     
         6 . The computerized method of  claim 1  wherein setting a claims cost target comprises setting a claims cost target below a market trend. 
     
     
         7 . The computerized method of  claim 1  wherein said administrative fee is selected from the group consisting of medical claims administration, utilization, case management, radiology and transplant management, personal nurse care services, predictive modeling services, eligibility management, pharmacy administration, core wellness programs, toll free access to customer service via telephone, interactive voice response systems, ongoing identification card administration, state surcharge reporting, annual plan sponsor summary for government filings, bank and funding arrangements, employee and enrollment communication materials, standard monthly reporting package, summary plan description preparation, Internet access to summary plan description, and designated service unit. 
     
     
         8 . The computerized method of  claim 1  further comprising:
 (j) receiving at said server at least one service performance metric related to administration services provided by said health care plan administrator to said sponsor for administration of said health care plan; and 
 (k) reducing said administrative fee if said health care plan administrator fails to meet said at least one service performance metric. 
 
     
     
         9 . The computerized method of  claim 8  wherein said service performance metric is selected from the group consisting of claims cycle time, financial accuracy, payment accuracy, telephone response rate, telephone abandonment rate, and account installation. 
     
     
         10 . A computerized method for tracking reductions in a health care administration costs comprising:
 (a) receiving at a server administrative fee data comprising fees charged by a health care plan administrator to a sponsor of a health care plan for a plurality of members of a member population;   (b) receiving at said server a plurality of member engagement factors related to plan activities completed by members of said health care plan;   (c) receiving at said server member participation targets for each of said member engagement factors;   (d) receiving at said server a claims cost target for said sponsor according to a measure of actual member participation against said member participation targets wherein said claims cost target is a cap on claims cost growth for said member population during an applicable health care plan period;   (e) comparing at said server actual claims cost data against said claims cost target for said applicable health care plan period;   (f) determining at said server administrative fees charged to said sponsor in relation to difference between said actual claims cost data and said claims cost target   (g) adjusting an administrative fee to be paid by said sponsor according to said members' progress toward each target participation level for each of said plan activities; and   (h) generating a claims cost scorecard comprised of a first column indicating a predetermined weight to be given said plan activities, a second column indicating said target participation level for said plan activities, a third column indicating said actual participation level for said plan activities, and a participation score.   
     
     
         11 . The computerized method of  claim 10  wherein said member engagement factors are selected from the group consisting of providing a valid telephone number, completing a health assessment, participating in a health care program, and participating in a pharmacy cost reduction plan. 
     
     
         12 . The computerized method of  claim 11  wherein participating in a health care program comprising participating in a clinical program. 
     
     
         13 . The computerized method of  claim 12  wherein participating in a clinical program comprises participating in a clinical program for disease management. 
     
     
         14 . The computerized method of  claim 10  wherein determining at said server administrative fees charged to said sponsor comprises determining an administrative fee refund to said sponsor. 
     
     
         15 . The computerized method of  claim 10  wherein establishing a claims cost target comprises establishing a claims cost target below a market trend. 
     
     
         16 . The computerized method of  claim 10  wherein said administrative fees are selected from the group consisting of medical claims administration, utilization, case management, radiology and transplant management, personal nurse care services, predictive modeling services, eligibility management, pharmacy administration, core wellness programs, toll free access to customer service via telephone, interactive voice response systems, ongoing identification card administration, state surcharge reporting, annual plan sponsor summary for government filings, bank and funding arrangements, employee and enrollment communication materials, standard monthly reporting package, summary plan description preparation, Internet access to summary plan description, and designated service unit. 
     
     
         17 . The computerized method of  claim 10  further comprising:
 (i) receiving at said server at least one service performance metric related to administration services provided by said health care plan administrator to said sponsor for administration of said health care plan; and 
 (j) reducing said administrative fee if said health care plan administrator fails to meet said at least one service performance metric. 
 
     
     
         18 . The computerized method of  claim 17  wherein said service performance metric is selected from the group consisting of claims cycle time, financial accuracy, payment accuracy, telephone response rate, telephone abandonment rate, and account installation. 
     
     
         19 . A computerized method for determining health care plan administrative fees comprising:
 (a) receiving at a server health care plan data for a health plan covering a plurality of health care plan members, said health care plan defined by a health care plan administrator;   (b) calculating administrative fees to be paid by a sponsor of said health care plan for administration of said health care plan for said plurality of members, said administrative fees calculated by said health care plan administrator;   (c) receiving at said server activity data for a plurality of activities to be completed by said members of said health care plan;   (d) associating at said server with each activity a target participation level by said members of said health care plan;   (e) receiving at said server measurements during an applicable plan period of said members' progress toward each target participation level for each activity;   (f) adjusting said administrative fees to be paid by said sponsor according to said members' progress toward each target participation level for each activity; and   (g) generating a claims cost scorecard comprised of a first column indicating a predetermined weight to be given said plan activities, a second column indicating said target participation level for said plan activities, a third column indicating said actual participation level for said plan activities, and a participation score.   
     
     
         20 . The computerized method of  claim 19  wherein said plurality of activities are selected from the group consisting of providing a valid telephone number, completing a health assessment, participating in a health care program, and participating in a pharmacy cost reduction program. 
     
     
         21 . The computerized method of  claim 20  wherein participating in a health care program comprises participating in a clinical program. 
     
     
         22 . The computerized method of  claim 21  wherein participating in a clinical program comprises participating in a clinical program for disease management. 
     
     
         23 . The computerized method of  claim 19  wherein said administrative fees are selected from the group consisting of medical claims administration, utilization, case management, radiology and transplant management, personal nurse care services, predictive modeling services, eligibility management, pharmacy administration, core wellness programs, toll free access to customer service via telephone, interactive voice response systems, ongoing identification card administration, state surcharge reporting, annual plan sponsor summary for government filings, bank and funding arrangements, employee and enrollment communication materials, standard monthly reporting package, summary plan description preparation, Internet access to summary plan description, and designated service unit. 
     
     
         24 . The computerized method of  claim 19  further comprising:
 (h) receiving at said server at least one service performance metric related to administration services provided by said health care plan administrator to said sponsor for administration of said health care plan; and 
 (i) reducing said administrative fees if said health care plan administrator fails to meet said at least one service performance metric. 
 
     
     
         25 . The computerized method of  claim 24  wherein said service performance metric is selected from the group consisting of claims cycle time, financial accuracy, payment accuracy, telephone response rate, telephone abandonment rate, and account installation.