MEDICAID AND MEDICARE
DATA SCIENCE & ANALYTICS
Knowli supports data-driven decision making by providing the following data science solutions.
Forecasting, statistical, and predictive analytics
- Identification of potentially preventable admissions, conditions, ED visits and readmissions
- Population trending and forecasting
- Social Determinants of Health Data Blending
- Pattern Detection via machine learning
Modeling Capabilities
- Risk Score Model Selection and Application
- Social Determinants of Health Data Modeling
- Special Population Risk Scoring and Adjustment Models
Medicaid data validation and management
- Encounter data validation (completeness, timeliness, accuracy)
- Custom ETL, cleansing, and combining disparate data sets (NCPDP, CMS-1500, X-12, ENS, EHR, hospital-reported data, provider and member enrollment)
Algorithm Development and Implementation for Identification of Special Populations:
- HIV/AIDS
- Serious Mental Illness
- Substance Abuse Disorders
- Hemophilia
- Full-time Private Duty Nursing
Dashboarding and reporting
- Up-to-date population monitoring (SMI, SUD, HIV/AIDS, PDN, general enrollment)
- Up-to-date service utilization monitoring (ED visits, vaccinations, telemedicine, behavioral analysis)
- Financial reporting and reconciliation (achieved savings rebate, capitation payment monitoring, cost reporting)
Creating customized analytical tools
- Provider network assessment tools
- Data entry tools for analysts
- Progress tracking tools for contract managers
- Data Exploration tools for decision makers
ACTUARIAL AND OPERATIONAL SUPPORT SERVICES
Our team provides the following services:
- Eligibility and Benefit Change Impact Analysis
- Service Delivery and Payment Model Evaluation
- Capitation Payment Analysis and Reconciliation
- Data Preparation Capitation Payment Rate Setting: Managed Care Medical Services, Long-term Care Services, Acute Care Hospitals
- Specialty Population Analysis
- Official responses to public records requests
- System development for evolving programs
- Executive decision support
- Scenario modeling for executive decisions
- Implementation assistance for program rollouts
- Data preparation for use in official public communications (Twitter, Facebook, LinkedIn)
- Executive summary preparation for presentations to Governor’s Office, Legislature, and public workgroups
HEALTH OUTCOMES ASSESSMENT AND METRIC DEVELOPMENT
Knowli’s team conducts comprehensive and systematic ongoing reviews of Medicaid program utilization as well as targeted reviews, profiles, and specialized analysis and decision-support services.
- Value-based performance goals for MCOs, provider groups, and facilities
- Birth outcomes measures (primary c-section rate, prenatal and postpartum visits, NAS LOS)
- Coding HEDIS and CMS Core-set metrics
- Cancer screening adherence
- HIV anti-retroviral drug adherence
- LTC care-setting transition rate from SNF to HCBS
MANAGED CARE ORGANIZATION MONITORING AND PERFORMANCE EVALUATION
In addition to designing custom tools for ITN scoring and Health Plan contract implementation, Knowli’s team creates metrics to monitor Health Plan performance and health outcomes of members over the duration of plan contracts.
- Managed Care Implementation Support
- ITN Scoring Tools
- MCO Readiness Assessment
- Progress Tracking Tools for Contract Managers
- Readiness Dashboard for Leadership
- Health plan delivery system evaluation
- Provider network assessment
- Reconciliation of plan-submitted financials with claims data
- Contractual goal assessments
- Plan-to-plan comparisons across a variety of metrics
- Long-term care program support
FEDERAL REPORTING
Our team supports programs by completing annual and quarterly analyses for federal reporting purposes, including:
- Early and Periodic Screening, Diagnostic, and Treatment
- CMS-416
- CMS-64
- CMS Audit Response
- CMS Core-set
PROGRAM INTEGRITY
Knowli’s team provides technical assistance to programs in researching problems, reviewing reports, establishing report parameters, and analyzing Fraud and Abuse Detection data.
- Cost Avoidance Reporting
- Service limit evaluations (durable medical equipment, behavioral analysis, home health visits)
- Enrollee/provider Rx relationship analysis
- Health plan “cherry picking” and “lemon dropping” analysis (newborns, LTC care-setting, members with special conditions)
- Active provider vs. terminated provider relationship mapping
- Valuation of program cost avoidance due to “Sentinel Effect”