Simplicity Health Your Health Your Money Your Choice. It's That Simple IBM Business Partner

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Real-Time Data

Simplicity Health Plans captures critical medical and pharmacy data at the point of service in real-time.

Think of it this way: Providers want to be paid as soon as possible. It takes approximately 30 seconds to submit a claim and be paid by Simplicity Health Plans. Done. Providers get their money. Simplicity Health Plans gets the medical and pharmacy data to evaluate and monitor the health of the group. It's that simple.

No health plan administrator offers the self-insured Employer access to such critical data on as timely a basis. Time equates to money. Better and more timely data means the ability to optimize utilization – offering Members better health outcomes at the most cost effective price.

Earlier Intervention

Simplicity Health Plans has incorporated into its claims engine 56 Disease State Triggers indicative of chronic or catastrophic claims. Additionally, pharmacy code data for drugs linked to these Disease States has also been programmed into our claims processing parameters.

On a real-time basis – using either (or both) medical billing or pharmacy drug codes – Simplicity Health Plans Case Management professionals, also known as Member Nurses, can identify what is happening within a group. When a trigger is hit, a Member Nurse is immediately notified by e-mail.

For example, Simplicity Health Plans Member Nurses can identify first-time users of drugs used to treat chronic conditions such as asthma and diabetes. The data below shows the cross-reference between medical billing codes (ICD-9) and just two of over 2,600 prescriptions (NDC-11) used to treat these diseases.

Condition ICD-9 NDC-11*
Asthma: 493 Albuterol
Diabetes: 250 Micronase

* Over 1,300 NDC-11 code triggers for each asthma and diabetes are loaded into our system

Simplicity Health Plans system will also track compliance with maintenance medications and offer suggestions to avoid unnecessary drug interactions. Member Nurses review on a daily basis the triggers that are initiated based on submitted medical & pharmacy codes. They will immediately initiate an intervention to assess the health condition of the Member and offer advice on how to best manage it.

It is common for chronically ill patients to be under the care of multiple Providers with each treating a separate condition. Delays in assessing the full scope of a Member’s health needs (across multiple conditions & Providers) and then coordinating a holistic approach for a rapid “return to health” may not only add expense but also provide a less favorable medical outcome.

Simplicity Health Plans Member Nurses have at their fingertips the best and most timely data available in the industry - spanning the full scope of medical services being used by each Member. Their “high touch” approach to Case Management ensures an immediate outreach to engage Members as active participants in their care, ultimately providing better medical outcomes at the most cost effective price.

Robust Analytics & Reporting

Simplicity Health Plans data warehouse has over 4 million lives of medical and pharmacy claims data. An extensive, artificial intelligence based analytics capability is available to all Employers/Plan Administrators to measure performance.

Benchmarking is easy and accurate. Claims experience housed in the data warehouse can be broken down by group demographics, industry, region of the country, and plan design. Each group’s experience can then be compared to the warehouse and progress measured.

The Simplicity Health Plans data warehouse also offers a robust lost cost-modeling tool. This tool uses actual medical and pharmacy data to project the “healthiness” of each group and the anticipated costs on a going forward basis. Budgeting and plan design have never been easier or more statistically relevant.

A detailed graphically enhanced reporting package is included in the Simplicity Health Plans Employer portal. Financial reporting data is updated daily for the Employer to obtain a snapshot of the Plan’s performance at any moment in time.