business intelligence and claim management - aascif conference 2013/b.i.as.enabler.of... ·...

Business Intelligence and Claim Management

MEMIC’s Medical Data Mart

Presenter: Matthew Holbrook, MEMIC

Business Intelligence and Claim Management MEMIC’s Medical Data Mart

Biography • Director of IT Applications, MEMIC. • 17 Years with MEMIC (24 years in IT overall). • Also worked for May Department Stores and Cap

Gemini • Graduate of Fordham University, Bronx NY


Goal

Provide an overview of how MEMIC decided to implement a medical data mart for its Claim Management team.


Why build a medical data mart in the first place?


According to NCCI: • Medical services now constitute almost 60% of

workers compensation (WC) claim costs, up from about 40% in the early 1980s.

• Prescription drug expense makes up 19% of all workers compensation (WC) medical costs.

Sources: NCCI Research Brief s “ Medical Services by Size of Claim—2011 Update “, November 2011 and “ WORKERS COMPENSATION PRESCRIPTION DRUG STUDY: 2011 UPDATE “ , August 2011.


Other Reasons

• Drug Use and Drug Abuse • Optimizing Claim Outcomes • Comparing Provider Performance


Questions to be answered • How much have we spent on PT this year for

policyholder XYZ’s claims? • What is the turnaround time for processing medical

bills at our MBR vendor? • The ABC Company wants to know how much

MEMIC saved on prescriptions this year.


Medical Bill Process


Medical data available • Procedure lines and modifiers • Provider charges and allowance • Fee schedule and PPO savings • Diagnosis codes • MBR review fees and PPO costs


Prescription Billing Process


Prescription data available • NDC numbers and GPI categories • Generic status; new fill vs. refills • Ingredient and AWP costs • Prescriber and pharmacy information


Prior Attempts to Get a Handle on Medical Data • Through a medical data aggregator • Through the vendors themselves • Through internal development with IT (generally ad

hoc)


MEMIC’s Beacon Data Warehouse • Developed by Millbrook (now part of Guidewire). • Implemented in 2001. • Converted over to Business Objects in 2008. • Stores large amounts of policy and claim data.


The Road to the Data Mart • Millbrook had developed a data mart within

Beacon for the Montana State Fund. • In mid-2011, Millbrook demonstrated the data

mart to MEMIC Claim and IT staff. • By late 2011, a contract was signed to build one for

MEMIC.


Project Phases 1. Initial Discovery and Requirements 2. Development 3. System and Regression Testing 4. Quality Assurance and User Acceptance Testing 5. Deployment


CompletionPhase Tasks Initial Est Likely ActualInitial Discovery & Requirements Phase Business Analysis Feb 2012 Feb 2012 Feb 2012

Data/Extract-Transform-Load AnalysisDocument Requirements (Report List, Gaps and Technical Roadmap)Data Modeling

Development Phase ETL Coding/Unit Testing/Rework Apr 2012 Apr 2012 Apr 2012Universe Coding/Unit Testing/ReworkReport Development/Universe Testing/ReworkCoding for extracts from MEMIC's AS/400 database

System & Regression Test Phase Full Data Load to Dev May 2012 May 2012 May 2012Full Load System & Regression Testing & Rework Delta Data Load to DevDelta Load System & Regression Testing & Rework

UAT & QA Testing Full Data Load to QA Jun 2012 Sep 2012 Mar 2013UAT & QA Testing- Data ValidationUAT & QA ReworkFinal UAT & QA Testing- Data Validation

Deployment Production Initial Load - Full Data Load Jun 2012 Oct 2012 Jul 2013Validate Production Initial LoadProduction Delta Load to CurrentValidation Production Delta Load to CurrentFinal Checkout/Regression Testing


Medical Data Mart Components Beacon: 4 new data collections or “universes” Medical Bills – EOM and transactions Pharmacy – EOM and transactions 11 report templates AS/400: Data extract jobs scheduled daily and monthly


Report Templates • Can be used OOTB or can be modified for user

preferences. • Basic types

– 12 Month summary reports – Drug utilization reports – Transaction detail reports

• Each template provides optional filters


Report Template Samples 1. Fiscal Year Medical Experience 2. Top 25 Pharmacy Billings 3. Utilization by Injured Worker


Sample Report: Fiscal Year Medical Experience

Value Date Claim Count Actual Charge03/31/13 9999 $9,999,999.9902/28/13 9999 $9,999,999.9901/31/13 9999 $9,999,999.9912/31/12 9999 $9,999,999.9911/30/12 9999 $9,999,999.9910/31/12 9999 $9,999,999.9909/30/12 9999 $9,999,999.9908/31/12 9999 $9,999,999.9907/31/12 9999 $9,999,999.9906/30/12 9999 $9,999,999.9905/31/12 9999 $9,999,999.9904/30/12 9999 $9,999,999.99Grand Total 9999 $9,999,999.99

State Loss Year

State Claim Count Actual ChargeArizona 999 $99,999.99Connecticut 999 $99,999.99Delaware 999 $99,999.99Florida 999 $99,999.99Georgia 999 $99,999.99Indiana 999 $99,999.99Kentucky 999 $99,999.99Maine 999 $99,999.99Maryland 999 $99,999.99Massachusetts 999 $99,999.99New Hampshire 999 $99,999.99New Jersey 999 $99,999.99New York 999 $99,999.99Pennsylvania 999 $99,999.99Rhode Island 999 $99,999.99Tennessee 999 $99,999.99Texas 999 $99,999.99Utah 999 $99,999.99Vermont 999 $99,999.99Virginia 999 $99,999.99Grand Total 999 $9,999,999.99

$999.99999 $9,999,999.99 $9,999,999.99 $9,999,999.99 $9,999,999.99 $99,999.99 $99,999.99999 $99,999.99 $99,999.99 $99,999.99 $99,999.99 $999.99

$999.99999 $99,999.99 $99,999.99 $99,999.99 $99,999.99 $999.99 $999.99999 $99,999.99 $99,999.99 $99,999.99 $99,999.99 $999.99

$999.99999 $99,999.99 $99,999.99 $99,999.99 $99,999.99 $999.99 $999.99999 $99,999.99 $99,999.99 $99,999.99 $99,999.99 $999.99

$999.99999 $99,999.99 $99,999.99 $99,999.99 $99,999.99 $999.99 $999.99999 $99,999.99 $99,999.99 $99,999.99 $99,999.99 $999.99

$999.99999 $99,999.99 $99,999.99 $99,999.99 $99,999.99 $999.99 $999.99999 $99,999.99 $99,999.99 $99,999.99 $99,999.99 $999.99

$999.99999 $99,999.99 $99,999.99 $99,999.99 $99,999.99 $999.99 $999.99999 $99,999.99 $99,999.99 $99,999.99 $99,999.99 $999.99

$999.99999 $99,999.99 $99,999.99 $99,999.99 $99,999.99 $999.99 $999.99999 $99,999.99 $99,999.99 $99,999.99 $99,999.99 $999.99

$999.99999 $99,999.99 $99,999.99 $99,999.99 $99,999.99 $999.99 $999.99999 $99,999.99 $99,999.99 $99,999.99 $99,999.99 $999.99

$999.99999 $99,999.99 $99,999.99 $99,999.99 $99,999.99 $999.99 $999.99999 $99,999.99 $99,999.99 $99,999.99 $99,999.99 $999.99

$999.99999 $99,999.99 $99,999.99 $99,999.99 $99,999.99 $999.99 $999.99999 $99,999.99 $99,999.99 $99,999.99 $99,999.99 $999.99

Bill Review Fee Amount

999 $99,999.99 $99,999.99 $99,999.99 $99,999.99 $999.99 $999.99Bill Count

Total Reductions

Line Allowed Amount

Line Network Reduction

Reduction Amount 1 Bill PPO Fee

Latest Value Date: 03/31/2013 Choose the First Column Company Claim Type Supervisor Body Part Group

Sum:

$99,999.9999999 $9,999,999.99 $9,999,999.99 $9,999,999.99 $9,999,999.99 $99,999.99 $99,999.9999999 $9,999,999.99 $9,999,999.99 $9,999,999.99 $9,999,999.99 $99,999.99

$99,999.9999999 $9,999,999.99 $9,999,999.99 $9,999,999.99 $9,999,999.99 $99,999.99 $99,999.9999999 $9,999,999.99 $9,999,999.99 $9,999,999.99 $9,999,999.99 $99,999.99

$99,999.9999999 $9,999,999.99 $9,999,999.99 $9,999,999.99 $9,999,999.99 $99,999.99 $99,999.9999999 $9,999,999.99 $9,999,999.99 $9,999,999.99 $9,999,999.99 $99,999.99

$99,999.9999999 $9,999,999.99 $9,999,999.99 $9,999,999.99 $9,999,999.99 $99,999.99 $99,999.9999999 $9,999,999.99 $9,999,999.99 $9,999,999.99 $9,999,999.99 $99,999.99

$99,999.9999999 $9,999,999.99 $9,999,999.99 $9,999,999.99 $9,999,999.99 $99,999.99 $99,999.9999999 $9,999,999.99 $9,999,999.99 $9,999,999.99 $9,999,999.99 $99,999.99

$99,999.9999999 $9,999,999.99 $9,999,999.99 $9,999,999.99 $9,999,999.99 $99,999.99 $99,999.9999999 $9,999,999.99 $9,999,999.99 $9,999,999.99 $9,999,999.99 $99,999.99

Bill Review Fee Amount

99999 $9,999,999.99 $9,999,999.99 $9,999,999.99 $9,999,999.99 $99,999.99 $99,999.99Bill Count

Total Reductions

Line Allowed Amount

Line Network Reduction

Reduction Amount 1 Bill PPO Fee

Business Intelligence and Claim Management MEMIC’s Medical Data Mart Sample Report: Top 25 Pharmacy Billings

GPI Drug GroupTotal

RxAvg

QuantityAvg Days

SupplyAvg Ingred.

CostAvg Rx

CostIngredient

CostAdministrative

FeeAvg Member

PaidAvg Plan

PaidBilled

AmountANALGESICS NARCOTIC 999 99.99 99,99 $999.99 $999.99 $999,999.99 $999.99 $999.99 $999.99 $999,999.99ANTI-RHEUMATICS 999 99.99 99,99 $999.99 $999.99 $999,999.99 $999.99 $999.99 $999.99 $999,999.99SKELETAL MUSCLE RELAXANTS 999 99.99 99,99 $999.99 $999.99 $999,999.99 $999.99 $999.99 $999.99 $999,999.99ANTIDEPRESSANTS 999 99.99 99,99 $999.99 $999.99 $999,999.99 $999.99 $999.99 $999.99 $999,999.99ANTICONVULSANTS 999 99.99 99,99 $999.99 $999.99 $999,999.99 $999.99 $999.99 $999.99 $999,999.99DERMATOLOGICAL 999 99.99 99,99 $999.99 $999.99 $999,999.99 $999.99 $999.99 $999.99 $999,999.99ANTIANXIETY AGENTS 999 99.99 99,99 $999.99 $999.99 $999,999.99 $999.99 $999.99 $999.99 $999,999.99ULCER DRUGS 999 99.99 99,99 $999.99 $999.99 $999,999.99 $999.99 $999.99 $999.99 $999,999.99CORTICOSTEROIDS 999 99.99 99,99 $999.99 $999.99 $999,999.99 $999.99 $999.99 $999.99 $999,999.99HYPNOTICS 999 99.99 99,99 $999.99 $999.99 $999,999.99 $999.99 $999.99 $999.99 $999,999.99ANTICOAGULANTS 999 99.99 99,99 $999.99 $999.99 $999,999.99 $999.99 $999.99 $999.99 $999,999.99LAXATIVES 999 99.99 99,99 $999.99 $999.99 $999,999.99 $999.99 $999.99 $999.99 $999,999.99ANALGESICS NON-NARCOTIC 999 99.99 99,99 $999.99 $999.99 $999,999.99 $999.99 $999.99 $999.99 $999,999.99ANTIPSYCHOTICS 999 99.99 99,99 $999.99 $999.99 $999,999.99 $999.99 $999.99 $999.99 $999,999.99ANTIASTHMATICS 999 99.99 99,99 $999.99 $999.99 $999,999.99 $999.99 $999.99 $999.99 $999,999.99ANTIHISTAMINES 999 99.99 99,99 $999.99 $999.99 $999,999.99 $999.99 $999.99 $999.99 $999,999.99ANTIHYPERTENSIVES 999 99.99 99,99 $999.99 $999.99 $999,999.99 $999.99 $999.99 $999.99 $999,999.99OPHTHALMICS 999 99.99 99,99 $999.99 $999.99 $999,999.99 $999.99 $999.99 $999.99 $999,999.99CEPHALOSPORINS 999 99.99 99,99 $999.99 $999.99 $999,999.99 $999.99 $999.99 $999.99 $999,999.99ANDROGEN-ANABOLIC 999 99.99 99,99 $999.99 $999.99 $999,999.99 $999.99 $999.99 $999.99 $999,999.99ANTIEMETICS 999 99.99 99,99 $999.99 $999.99 $999,999.99 $999.99 $999.99 $999.99 $999,999.99MIGRAINE PRODUCTS 999 99.99 99,99 $999.99 $999.99 $999,999.99 $999.99 $999.99 $999.99 $999,999.99DECONGESTANTS 999 99.99 99,99 $999.99 $999.99 $999,999.99 $999.99 $999.99 $999.99 $999,999.99MEDICAL DEVICES 999 99.99 99,99 $999.99 $999.99 $999,999.99 $999.99 $999.99 $999.99 $999,999.99STIMULANTS 999 99.99 99,99 $999.99 $999.99 $999,999.99 $999.99 $999.99 $999.99 $999,999.99

999 99.99 99,99 $999.99 $999.99 $999,999.99 $999.99 $999.99 $999.99 $999,999.99

Business Intelligence and Claim Management MEMIC’s Medical Data Mart Sample Report: Utilization by Injured Worker

Claim Number Claimant Total Rx

Ingredient Cost

Dispensing Fee

Administrative Fee

Copay Amount 1

Billed Amount

99999981 PIPE CLEANER 91 $2,711.30 $42.75 $37.20 $0.00 $2,754.0599999982 JUICE WATERBOTTLE 58 $12,441.00 $49.50 $24.60 $0.00 $12,490.5099999983 WEB BROWSER 51 $907.71 $9.00 $18.00 $0.00 $916.7199999984 BARR TENDER 47 $2,011.02 $38.25 $20.40 $0.00 $2,049.2799999985 SOUND BOARD 40 $1,336.51 $63.00 $22.20 $0.00 $1,399.5199999986 CARE PACKAGE 34 $1,286.68 $42.75 $16.80 $0.00 $1,329.4399999987 PICKLED HERRING 32 $2,289.79 $49.50 $16.80 $0.00 $2,339.2999999988 BAG BALM 28 $1,705.67 $33.75 $13.80 $0.00 $1,739.4299999989 CAL ZONE 28 $2,521.41 $33.75 $13.80 $0.00 $2,555.1699999990 PEER REVIEW 27 $1,235.97 $9.00 $10.80 $0.00 $1,244.9799999991 KETTLE STOVE 25 $1,999.91 $33.75 $12.60 $0.00 $2,033.6699999992 DOOR KNOB 25 $220.44 $18.00 $12.00 $0.00 $238.4499999993 CHEESE GRATER 24 $1,897.50 $45.00 $13.80 $0.00 $1,942.5099999994 CAL DE SAC 23 $7,119.64 $27.00 $10.80 $0.00 $7,146.6499999995 CONNING TOWER 23 $85.37 $20.25 $10.80 $0.00 $105.62


Questions?


Thank you!

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