ModrinumUtilisation reporting
Numbers you can take into a budget meeting
A vendor who can quote the premium but cannot show incurred claims ratio by month is broking, not administering. Reporting is the part of this work that decides next year's cost, and it has to arrive early enough to act on — which means monthly, in a form a finance director reads without a glossary.
What is in the monthly pack
Delivered by the tenth working day, covering the month just closed, with the prior twelve months alongside for shape.
| Measure | How we compute it | The decision it informs |
|---|---|---|
| Incurred claims ratio | Claims paid plus outstanding reserves for the period, divided by premium earned for the same period | Whether the policy is running towards a loading, and how large |
| Claim count and average size | Settled claims in the month, split cashless and reimbursement | Distinguishes a bad month caused by one large claim from one caused by volume |
| Corporate buffer burn | Buffer drawn to date against opening balance, with the drawing claims named | Whether the buffer survives to renewal, and by how much to top it up |
| Sub-limit dispute count | Claims where a deduction was applied under a named sub-limit, counted by limit | Which limit to renegotiate at renewal, priced against its real cost |
| Diagnosis mix | Top ten diagnosis groups by claim value and by count | Where a wellness or screening intervention would actually pay back |
| Claimant profile | Claims split employee, spouse, child, parent, and by age band | Whether the parental block is driving the ratio, which is often the case |
| Turnaround times | Median days from intimation to approval, and from document completion to settlement | Whether the TPA is meeting its service standard, evidenced rather than asserted |
| Rejection and deduction analysis | Every rejected claim with the clause relied on, and total deductions by reason | What to fix in enrolment communication so it stops recurring |
| Helpdesk volume by category | Tickets grouped: e-card, cover query, claim status, enrolment, flexi | Where the plan is not being understood, before it becomes a claim dispute |
Cleaning the data first
A TPA claim dump is not a report. It arrives with the same hospital appearing under four spellings, employee codes that do not match your HRIS, diagnosis text typed free-hand, and claims dated by intimation in one column and by admission in another. If you paste it into a pivot table you will get a confident answer to the wrong question.
Before anything is charted we map hospital names to a standardised list, map employee codes to your master, classify diagnosis text into groups, and reconcile the claim register against what the insurer's account statement says was paid. Where the two disagree — and on a first month they usually do, by a percent or two — we resolve the difference rather than reporting the friendlier number.
The pack states its own basis on the front page: period covered, whether reserves are included, the extraction date, and any claim excluded and why. A number without its basis is not usable in a negotiation.
Reading incurred claims ratio
Below about 70 per cent, the policy is comfortable and renewal should be flat or better. Between 70 and 100, expect a discussion. Above 100 the insurer is paying out more than it collected, and a loading is arriving.
The trap is timing. A ratio computed at month six on a policy that renews in month twelve looks reassuring, because claims incurred late in the year have not been reported yet. We report both the reported ratio and a developed estimate that allows for the lag, so the number at month six is one you can still plan against.
The Kolkata curve
Utilisation in this city is not flat, and budgeting as though it were produces a second-quarter surprise every year. Across the accounts we administer, admissions climb through July and August with dengue and viral fever, ease in the autumn, and climb again in February when planned procedures get scheduled after appraisals and bonus payouts. Cataract and orthopaedic cases cluster in the cooler months. If your buffer is sized on an average month, it will be under pressure precisely when two of those effects overlap. We size it on the curve and tell you in advance which month will read badly, so the report is a confirmation rather than an alarm.
The reporting calendar
- Tenth working day, every month Monthly pack Emailed to the HR and finance recipients you name, as a PDF for reading and a workbook for anyone who wants to cut it themselves. Two pages of commentary at the front saying what changed and what we think it means.
- Every quarter Utilisation review Ninety minutes at your office or on a call, with the account manager and the claims coordinator present. Agenda: ratio trend, buffer position, the three sub-limits generating the most disputes, open claims older than fifteen days, and any change we recommend to the plan.
- Renewal minus 120 days First renewal projection A developed claims ratio, an expected loading range, and two or three structural options — a sub-limit change, a buffer resize, a co-pay on the parental block — each priced so the conversation is about trade-offs rather than sentiment.
- Renewal minus 60 days Frozen data set Census, age-band distribution, claims MIS mapped to your member codes, and a written note of any data quality caveat. This is what your broker takes to market. It is ready before it is asked for.
- Renewal minus 15 days Quote comparison support We read the quotes on their wording, not their headline premium: room-rent basis, co-pay, waiting periods, ailment caps, portability of the buffer. A cheaper quote with a one per cent room cap is not cheaper.
- Renewal plus 30 days Post-renewal reconciliation New policy schedule checked line by line against what was agreed, member master reloaded, e-cards reissued, and the plan summary rewritten wherever a term changed.
Rewards and wellness fulfilment reporting
Where we also run the rewards side, the same discipline applies to programmes that are usually reported as attendance and nothing else.
Health check camps
Invited, booked and attended counts by location and grade, cost per completed check, and the anonymised abnormality rate by test. That last figure is the only one that tells you whether the camp was worth repeating.
Doctor-on-call and teleconsult
Consultations used against the entitlement, repeat usage, and the share of calls that avoided an OPD visit. Reported monthly with the utilisation pack.
Reward and recognition fulfilment
Vouchers issued, redeemed and expired, by scheme and by month, with unredeemed value flagged before it lapses. Expired value is money the employer spent and the employee never received.
Send last year's claims MIS
We will clean it, compute the developed ratio, name the sub-limits doing the damage and give you a renewal position — in five working days, on your current policy, with no requirement to change anything.