Softheon, a proven leader in cloud-based health insurance marketplace integration and a certified Web Broker Entity, has announced the availability of big data and business intelligence capabilities within Softheon Marketplace Connector Cloud (MC2).

Profit & loss (P&L) analysis is based on enrollment, premium billing, and claims data that Softheon MC2 collects and processes as part of daily operations and compliance reporting. Softheon has developed the real-time data-driven solution to address insurance carriers’ challenges in order to better understand, not just member acquisition, but also utilization. Therefore, closing the loop with valuable feedback for actuarial processing.

With claims, enrollment, and payment data under one repository, Softheon is uniquely positioned to provide data analysis for financial oversight and sustainable business operations. Softheon provides health insurers with more than just a large spreadsheet of miscellaneous information, instead, Softheon’s executive dashboard brings a true visualization of P&L analytics by including:

Member demographics (male vs. female)

Age band (18-35 vs 55-63)

County and Zip code geographical distribution

QHP HIOS plan (most or least profitable ACA plan)

Distribution channel (On vs Off Exchange)

Broker book of business (profitability by demography or QHP)

All P&L reports provide drill down analytics with options to view data at a quarterly, monthly, and daily level, whereby insurers can determine the plans that contribute the least amount of revenue, etc.

Claims analysis also reveals trends towards better utilization management, fraud, waste, and abuse anomalies among the providers with high claim payout for the same ICD/CPT code.

"The data-driven business model is critical to the success of insurers in exchanges as it was evident in recent announcements from carriers exiting ACA or shutting down. However, with our P&L Business Intelligence, we are able to quickly identify risk, such as providers charging as much as 8 times for the same ICD/CPT code, in real-time," said Eugene Sayan, Softheon CEO & Founder.

Softheon not only provides insight into the data, but also delivers feedback to carriers to help them utilize the given information to increase profitability in areas of low revenue. Softheon’s team has found that some providers are charging over four times more than other providers for the same service. They have also identified October to be the month with the least net revenue despite observing a peak in overall claims.