AI Claims Trend Analysis Agent
Automating Claims Trend Analysis with AI
Unified data ingestion and normalization
The Agent automatically ingests claims feeds from carriers, PBMs, and vendors, then standardizes code sets (ICD-10, CPT, NDC) and applies data quality checks to create a single, analysis-ready dataset.
Risk-adjusted trend decomposition
Automated risk scoring and episode grouping enable apples-to-apples comparisons, while trend analysis breaks down PMPM changes into price, utilization, and mix components surfacing the drivers behind your numbers.
Cohort analysis and opportunity sizing
The system identifies high-cost claimants, rising-risk members, and condition cohorts, then models intervention ROI using matched controls and difference-in-differences methods with built-in bias guardrails.
How Cassidy automates this using AI
Step 1: Ingest and normalize claims data
The Workflow triggers on new data feeds from medical carriers, PBMs, and specialty vendors. Cassidy standardizes eligibility, claims, and pharmacy files mapping to ICD-10, CPT, NDC, and DRG code sets while applying completion factors for IBNR estimation.
Step 2: Run risk adjustment and episode grouping
Cassidy calculates risk scores and groups claims into clinical episodes, enabling case-mix-adjusted comparisons across time periods and populations. Member attribution and cohort definitions (high-cost claimants, chronic conditions, specialty Rx users) are applied automatically.
Step 3: Decompose trends and surface drivers
The Agent breaks down PMPM trend into price, utilization, and severity components. It ranks top cost drivers by condition, site of service, and vendor flagging anomalies like GLP-1 spend acceleration or site-of-care opportunities.
Step 4: Model ROI and size opportunities
Cassidy runs matched-control and difference-in-differences analyses on intervention cohorts, calculating net savings with confidence intervals. Scenario simulations model plan design changes, steerage strategies, and vendor optimizations.
Step 5: Generate executive summaries and recommendations
The Workflow produces CFO-ready decks with trend heatmaps, driver rankings, and quantified ROI cases. Human-in-the-Loop review ensures recommendations from benefit changes to COE steerage are validated before stakeholder delivery.
Implement it inside your company
- Hands-on onboarding and support
- Self-paced training for your team
- Dedicated implementation experts
- Ongoing use case discovery
- ROI tracking & analytics dashboards
- Proven playbooks to get started fast
