standard management reports

Descriptions of Reports
Managed Care Payer Reporting System: Analysis and Trend Reporting Module

Category	Report Name	Description	Purpose	*Data Source*
Medical Cost	Executive Cost & Revenue Report	Premium revenue, medical cost, admin cost & MLR by carrier/product/lob trended monthly, quarterly, annually, YTD	High level margin and medical cost monitoring, Budgeting, Strategic planning	Paid medical claims IBNR Premium info
Medical Cost	Summary Medical Cost Report	PMPM costs in broad medical cost categories (hospital, physician FFS, capitation, pharmacy) trended monthly, quarterly, YTD by region	Identification of high cost and cost change trends in broad service categories for medical management opportunities	Paid medical claims IBNR
Medical Cost	Comparative Medical Cost Report	PMPM costs, cost/unit and utilization rates for approximately 60 service categories allowing user to specify 2 sets of date ranges. Breakdowns are available by area, PCP, specialty, group, plan, carrier/product/lob	Identification of high cost and cost change trends in specific service categories for medical management opportunities	Paid medical claims IBNR Member demographics Enrollment
Medical Cost	Provider Specialty Report	Paid FFS $, FFS PMPM capitated $ and capitated PMPM by provider specialty	Cost effectiveness of capitated services, reimbursement modeling, contracting support	Paid medical claims Paid capitation dollars Member demographics Enrollment
Medical Cost	Capitated Services Leakage Report	Comparison of incurred capitated paid services to incurred FFS paid services	Identification and monitoring of overlapping services being paid by both a capitated payment and FFS payments	Paid medical claims Paid capitation dollars
Medical Cost	A/E Inpatient Cost per Case	Actual / expected cost per inpatient admission by provider	Identification of cost effectiveness of inpatient contracts and evaluation of provider side case management effectiveness	Authorizations Case management Paid medical claims
Utilization Management	Comparative Inpatient Utilization Report	Number of admissions, number of beddays, admissions per 1,000 members, beddays per 1,000 members, and $/admission by inpatient facility, bedtype/service,	Monitoring of inpatient utilization trends for identification of medical/case management opportunities	Authorizations Case management Paid medical claims Member demographics Enrollment
Utilization Management	A/E LOS Report	Actual / expected length of stay by inpatient facility by DRG	Medical/case management effectiveness of individual inpatient facility compared to entire network	Authorizations Case management Paid medical claims
Utilization Management	Inpatient Utilization By Network & Hospital Report	Top 10% cost hospitals. Included are hospital, discharges, days, ALOS, in and out of network dollars, $/discharge and $/day by carrier/product/lob/network	Identify facilities for case management activity, identify disease specific medical management opportunity	Authorizations Case management Paid medical claims
Utilization Management	Top MDCs/Diagnoses Report	Summarized inpatient costs by Major Diagnostic Category and diagnoses category. Included is: MDC, 1st digit ICD9, in and out of network dollars and % of total dollars.	Target areas for disease management	Authorizations Case management Paid medical claims
Utilization Management	Catastrophic Case Management Report	Detail encounter and clinical information for patients incurring >$X or >Y severity index	Identify candidates for prospective case management and stop loss coverage	Authorizations Case management Paid medical claims
Utilization Management	Pharmacy Utilization Report	Scripts, refills, brand:generic ratio, and cost by therapeutic class	Identification of drug utilization trends, identification of case management opportunities, formulary development	Paid pharmacy claims data
Utilization Management	Top Drugs Report	Most commonly prescribed drugs by therapeutic class, drug name; Most costly drugs by therapeutic class, drug name	Identification of drug utilization trends, identification of case management opportunities, formulary development	Paid pharmacy claims data
Utilization Management	H.E.D.I.S. Reporting	Prenatal care, well child/adolescent visits, C-section rates	Appropriate utilization of services, regulatory reporting	Authorizations Case management Paid medical claims Member demographics Enrollment Provider demographics Eligibility
Network Management	Provider Profiling Report	Case-mix adjusted actual / expected PMPM cost by major service category (IP, OP, prof, rad, pharm), actual / expected office visits, procedures and referrals by provider, trended quarterly, annually, YTD	Evaluation and feedback of provider practice patterns as a tool for behavior change to improve cost effectiveness of care	Authorizations Case management Paid medical claims Member demographics Enrollment Pharmacy Case-mix indexing / episode building criteria
Network Management	In vs. Out of Network Report	Costs, admissions, procedures, and visits by in network vs. out of network, service type, and carrier/product/lob/network	Network management tool for monitoring appropriateness and effectiveness of provider network and availability of network services, strategic network planning	Paid medical claims
Network Management	Unique In vs. Out of Network Utilizer Report	Number and percent of members utilizing in network exclusively, out of network exclusively or both in and out of network providers trended over time	Evaluate member behavior related to use of provider network	Paid medical claims
Network Management	Provider Panel Penetration Report	Number of plan members in PCP’s panel and as a percentage of total PCP panel, trended quarterly and YTD	Measure of plan leverage with PCP for reimbursement negotiation	Member demographics Enrollment Provider demographics Eligibility
Network Management	Provider Specialty : Member Ratio	Ratio of providers to members by specialty and carrier/product/lob	Appropriateness of provider network size and scope, needs assessment, access to care	Member demographics Enrollment Provider demographics Eligibility
Network Management	Provider Turnover	Number and percent of provider terminations and additions trended quarterly and YTD	Network stability	Provider Demographics
Network Management	H.E.D.I.S. Reporting	Access to preventive and primary care, availability of primary care, MH/SA, OBG care	Access to services, regulatory reporting	Authorizations Case management Paid medical claims Member demographics Enrollment Provider Demographics Eligibility
Quality Management	Re-admission Report	Percent of re-admissions within 7, 30, 90 and 180 days of previous discharge by MDC, PCP, region, carrier/product/lob	Identify member candidates and inpatient facilities for intervention and case management	Authorizations Case management Paid medical claims
Quality Management	Pregnancy-Drug Hazard Report	List of drug names and pregnant patients prescribed potentially hazardous drugs	Identification of pregnant patients prescribed potentially hazardous drugs	Authorizations Case management Paid medical claims Paid pharmacy claims data
Quality Management	H.E.D.I.S. Reporting	Immunizations, cancer screening, prenatal care/low birth-weight, childhood ear infections, beta blocker Rx, diabetic retinal exam, mental health follow-up	Effectiveness of care, regulatory reporting	Authorizations Case management Paid medical claims Member demographics Enrollment Provider demographics Eligibility
Enrollment	Enrollment Report	Number of enrollees and percent change monthly, quarterly, YTD, annually by group/carrier/product/lob	Plan stability, growth, revenue forecasting, strategic planning	Member demographics Enrollment Eligibility
Enrollment	Disenrollment report	Number and percent of voluntary and involuntary disenrollments by PCP/group/carrier/product/lob	Plan stability, growth, revenue forecasting, strategic planning	Member demographics Enrollment Eligibility
Enrollment	Member Demographics	Number and percent of members by group/carrier/product/lob, age and gender	Plan stability, growth, revenue forecasting, strategic planning	Member demographics Enrollment Eligibility