Abstract: The invention includes in one embodiment a method including receiving data associated with a health benefits plan of an entity. A report is automatically transmitted to the entity at a predetermined time associated with a repetitive business practice within a benefits cycle of the entity based on the data received. The report is associated with at least one feature of the health benefits plan of the entity. The method can also include receiving data associated with the health benefits plan of the entity associated with a second time interval or second entity, and automatically transmitting a report based on that data to the entity at a second predetermined time associated with the benefits cycle of the entity. The benefits cycle can be for, example, annual, monthly, quarterly, etc.

Abstract: The invention includes receiving a first data set that includes information associated with claims under a benefit plan. The first data set is searched for a first claim from the claims that includes at least one detail in common with a second claim from the claims. A report including the first claim and the second claim is generated. A duplication of a charge for the first claim or a duplication of charge for the second claim included in a vendor invoice received from a vendor is identified. The invention also includes comparing a first electronic data set that includes information associated with claims paid by a vendor to a provider, to a second electronic data set that includes claims included in a vendor invoice to an employer to determine if a claim from the claims included in a vendor invoice has been included in a claim paid to a provider.

Abstract: Data associated with a benefit plan, including enrollment data and claims data, are compared to verify proper payment of claims. Additionally, other information, such as general ledger, employer account information, and employer organizations can be considered. Information can be output to a user, such as a plan administrator, in a form convenient for that user to quickly understand a large amount of information and how that information relates to a business or other entity administering the benefit plan. Various techniques can be used to estimate reserves, and can optionally use a claims lag triangle as input, including a claims lag report method, a earned premium method, and iterative method, and a regression method, for example.

Abstract: Data of one or more individuals associated with a benefit plan are analyzed. The data can include information about benefits provided to the one or more individuals under the benefit plan, such as a medical benefit plan, a prescription benefit plan, or a retirement benefit plan. One or more expenses of the benefit plan are modeled at least partially based on the analyzed data. The modeling includes determining a change in the one or more expenses based on modification of a parameter of the benefit plan.

Abstract: A system and method for developing and utilizing member condition groups (MCGs) determines whether an individual has been diagnosed with one or more diagnostic codes from a predetermined group of diagnostic codes. Each diagnosed individual is associated, based on the one or more diagnostic codes, with one or more member condition groups (MCGs), each MCG representing a group of individuals diagnosed with clinically related diagnostic codes. A healthcare-related cost, including a pharmacy cost, a disability benefit, a workers compensation benefit, a health benefit administration fee, or an absence cost, associated with each diagnosed individual from a predetermined MCG during a predetermined time period is determined. Additionally, a medical health benefits cost, which is distinct from the healthcare-related cost, can be determined for each diagnosed individual.