Claims-cost review for HMOs

When paid fee-for-service claims rise, see where the additional amount appears.

Stratum is developing a structured claims-cost review for HMO leaders. It helps finance, medical, claims and provider-network teams see whether the additional paid amount appears in particular months or types of care - such as inpatient care, outpatient care, medicines, laboratory tests or imaging - and what the responsible team should check next.

See What Your Team Receives Discuss a Claims Increase

The review shows where an increase appears in paid-claims data. It does not by itself explain why the increase happened or judge fraud, care quality, provider performance or management action.

Current stage: testing with non-client data. Live HMO claims are not being accepted for this review at this stage.

The Business Question

A higher paid-claims total does not show where your team should investigate.

An HMO may see a budget variance or pressure on its claims ratio without knowing which part of paid fee-for-service claims changed. A useful first view answers three practical questions:

Which months or claims payment runs account for the additional paid amount?
Which types of care account for more of paid claims than before?
Where suitable enrolment data are available, did the enrollee population change enough to affect the comparison?

These findings give finance, medical, claims and provider-network teams a shared starting point before they examine tariff changes, contract terms, provider submissions, authorisation patterns, claims-payment timing or other context held by the HMO.

Executive & Finance

Understand the claims-cost pressure.

See whether the additional paid amount is spread across the months being reviewed or appears mainly in particular months or claims payment runs. Where suitable, view the same period alongside the HMO’s enrollee population.

Medical & Claims

See which types of care account for more of paid claims.

Identify whether the difference appears in inpatient care, outpatient care, medicines, laboratory tests, imaging or another agreed category - and whether missing records or payment timing could distort the comparison.

Provider Network & Reimbursement

Know where to investigate further.

Use the identified months and types of care to decide where the HMO should check tariffs, contract terms, provider submissions, authorisation patterns or claims-processing timing. Stratum does not make those determinations.

Current scope: this first review covers fee-for-service claims recorded as paid for the agreed months or quarters. Capitation payments, administrative expenses, claims not yet recorded as paid and total medical cost are not combined into the same view.

What Your Team Receives

A clear breakdown of the increase - and the checks needed before your team acts.

The review is designed to give HMO leaders three practical outputs.

Included data

Data and comparison check

What was included, which months or quarters were compared and whether missing records, inconsistent service coding or claims-payment timing could affect the result.

Cost increase

Breakdown of the paid-claims increase

Which months, claims payment runs and types of care account for the additional paid amount, and whether their share of paid claims changed.

Management review

Executive review brief

The main findings, important limitations and focused questions for finance, medical, claims or provider-network teams.

Enrollee context: where suitable enrolment data are available, the HMO’s enrollee population for the same period can provide additional context. This review does not determine whether premiums or capitation rates are adequate.

Decision authority: the HMO retains every claims, clinical, reimbursement, provider-network, purchasing and management decision.

Start with the question - not a dataset.

An initial conversation is used to understand the business question and assess potential fit. No claims, patient or enrollee data are needed for that conversation.

Discuss the Question

Data & Safeguards

Know what was included, who can use the findings and what the findings cannot prove.

Before any data work, Stratum and the HMO agree the business question, who may use the findings, the minimum data needed, the paid claims and types of care included, and the rules for access, retention and use.

Findings are tied to the agreed data and assumptions. Data limitations are shown clearly, and an observed increase is not presented as proof of its cause.

Agreed purpose
Only necessary data
Restricted access
Findings traceable
Limits stated clearly

Company

Building trusted claims-cost review tools for African health financing, beginning in Nigeria.

Stratum operates through Stratum Core Systems, Inc., a Delaware-incorporated parent, and Stratum Core Systems Africa Limited, a Nigerian operating subsidiary. Current operations are based in Abuja, Nigeria. The parent leads product development and oversight; the Nigerian subsidiary supports contracting, implementation and approved data work in Nigeria.

Dr. Obinna Onyekwena, MD, MPH

Founder & CEO

Leads product direction, strategy, safeguards and institutional partnerships. His prior experience includes serving as Deputy Director, Infectious Diseases Advocacy, at the Gates Foundation.

Alexander Alozie

Co-Founder & Chief Technology Officer

Leads technology, secure data handling and product development.

Discuss Your Claims Question

What increase in paid fee-for-service claims is your HMO trying to understand?

Start with the organisational question. No dataset is required for an initial conversation.

“Which months and types of care account for the additional paid amount, and what should our team check next?”

Dr. Obinna OnyekwenaFounder & CEO

obionyekwena@stratumcoresystems.com United States number: +1 425 380 6000 Nigeria number: +234 903 913 9868 Current operations: Abuja, Nigeria

Do not submit patient, enrollee or employee identifiers - or claims, clinical records or other health data - through this form or by email.