Milliman HCG Grouping and Utilization Profiling Clause Samples

Milliman HCG Grouping and Utilization Profiling. The HCG Grouper categorizes healthcare claims data into Milliman's HCG categories (which are groupings of similar types of services). The ability to categorize healthcare claims data into the groupings is useful for many purposes including: • Benchmarking and Budgeting • Trending • Utilization Tracking • Average Charge Tracking • Analyzing the Claim Cost Dollar The Performance Measurement component of MedInsight provides a comprehensive performance measurement tool for health plans, insurers, and TPAs. It contains more than 145 financial, medical management, and operational measures covering every department and aspect ofthe organization. Nearly 70% ofthe performance measures contain associated Milliman benchmarks that describe the worst, median, and best performance in the industry for that measure. Examples ofperformance measures include: • Reversed and Adjusted Claims • Average Days Turnaround of Claims • Billed Amount of Claims in Inventory • Billed Amount of Denied Claims • Claims per FTE by Department • Claims per 1,000 Members by FTE • Number of New Members • Number of Claim Authorizations MedInsight's evidence based measures provide the ability to track over 130 evidence based, clinical measures. These can be used to measure compliance of providers and plans with EBMs of clinical care. In addition, Milliman will add and customize the measures to add additional measures as needed. This module also includes reporting and access to cubes containing EBMs. The MedInsight Risk and Severity Adjustment (RSA) engine utilizes age/sex and condition/episode profiling techniques to determine retrospective and prospective medical risk factors. The risk factors are used as primary input into rating, health risk, and provider profiling processes. The RSA engine is unique in the industry in that it develops risk factors, for 13 different utilization and cost measures, for each member for each month of eligibility. The risk factors, themselves, are presented as a multiplier ofthe total population for each ofthe utilization categories (defined as a risk factor of 1.0). Because the RSA engine develops factors for each patient for 13 utilization categories, the user is able to risk adjust not only total costs, but also specific measures like drug utilization and cost, inpatient days and costs, etc. This is invaluable in that each risk category inherently produces distinct utilization profiles. Symmetry's Episode Treatment Grouper (ETG) is integrated with the MedInsight...