8 Plan Modeling

Planwatch includes tools for modeling plan designs and a basic claim readjudication engine. This makes it possible to ask various types of What If? questions regarding how claims would have been paid differently given a modified design.

Adjudication engine

Historical claims data is fed into the readjudication engine along with a modified plan design. The engine readjudicates each claim with the modified plan settings member-by-member, charge-by-charge. The resulting simulated claims data is then compared to the actual claims data and series of reports are provided for evaluating the overall impact of the plan design as well as member disruption.

The following sections document the process of creating plan models and detail individual reports.

  1. 8.1  Creating Plan Models
  2. 8.2  Base Plan Design Options
  3. 8.3  Benefit Category Plan Design Options
  4. 8.4  The Readjudication Process
  5. 8.5  Summary Comparison Report
  6. 8.6  Benefit Comparison Report
  7. 8.7  Employee Impact Report