The top 7 self-funded data points you shouldn’t ignore

By Scott Bennett, Vice President of Access Innovation

Featured in BenefitsPRO’s Broker Innovation Lab


For brokers, one of the most commonly identified perks for self-funded clients is better access to data for analytics. However, knowing where to begin when digging into the data can be an overwhelming task.

If you’re looking to paint a clearer picture for your clients around achieved and potential cost-savings, you should start by securing access to past hospital claims data (inpatient and outpatient) in a machine-readable format. This can typically be acquired from your client’s Third-Party Administrator (TPA) or Administrative Services Organization (ASO). From there, you can craft a data-driven strategy around medical costs and how they impact your clients’ bottom line.

Here are seven data points to look for within those claims and the assumptions you can make once you have access.

1. The hospital National Provider Identifier (NPI). The hospital NPI allows you to uniquely identify hospitals. There are also data tables with equivalent elements, also known as crosswalks, available to identify the hospital’s “provider number” or Medicare number related to public reports. 

2. The hospital name, address, city and state.* These fields provide good circumstantial evidence to help narrow down a provider. 

3. The hospital revenue code. This field identifies the department related to the billing on the claim line. 

4. An identifier as to whether the claim is inpatient or outpatient. This field is typically on the claim (in the form of a number) and helps if the analysis is filtered for just outpatient or inpatient. 

5. The hospital Current Procedural Terminology (CPT) Code (if outpatient) and the hospital related diagnosis-related group (DRG) (if inpatient). These fields help identify the procedure or services related to the billing on the claim line, and the modifier identifies how the services relate to other services in the same claim. 

6. The hospital billed charge. This field is typically on the claim (in the form of a number) and acts as a starting point when comparing external public hospital financial data or external public claim pricing data (like Medicare). 

7. The hospital allowed amount. If this is provided, it is an excellent way to look at what was actually paid. Using the billed charge and other data, you can compare the payment to external public hospital financial data or external public claim pricing data (like Medicare) to see how the payment/discount matches costs and/or Medicare benchmarks. 

*Note: This field is not always reliable and can vary greatly from claim to claim.

Once you have access to these data points, use a charting software to visualize the findings and identify outliers or trends across provider utilization, payment amounts compared to public market data or procedure trends that may lead to future issues for the plan. In doing so, you can begin to craft a data-driven benefits strategy for your clients that focuses on cost-containment and easily paint yourself as the expert they need on their side. Not sure where to start? Give us a shout.

To take a deeper dive into cost-containment strategies that may be a valuable solution for your clients, register for our upcoming webinar, “Build the dream: Constructing a cost-containment ecosystem for your organization.”