Payers and providers both have a mission to keep members and patients healthy, but, too often, individuals end up in the emergency department (ED) due to avoidable exacerbations of care or because they are unaware of other options for their ailments. It is estimated that approximately a third of ED visits may be preventable, indicating factors that may include poor care management or challenges with healthcare access. Payers can utilize artificial intelligence on claims and other data sets to proactively identify those potentially needing care, before conditions deteriorate. Translating insight to action requires collaboration across analytics, technology, and business/clinical leaders.
Disclaimer: These materials describe analyses using established analytical methods based on third-party claims and electronic health record data sets that have not been independently verified. The information and approaches described are not intended to interfere with clinical judgment and do not constitute clinical, medical, legal, policy, or any other regulated advice, and do not contain all information needed to determine any decision or action.