Provider profiles for both servicing, prospect and market providers are enhanced with the addition of quality scores. Efficiency and Effectiveness are measured using three independent metrics at the individual practitioner level and organizations can choose any combination of the three, weighting each metric differently, if needed.
- Allowed Charge to Claim – A measure of “Charge Intensity”, useful for profiling providers relative to discrete events like PTCI or Colonoscopy
- Claims to Patients – A measure of “Encounter Intensity”, useful for profiling providers on number of services provided
- Allowed Charge to Patients– A measure of “Care Intensity, useful for profiling providers on overall cost per patient
- Mortality – Mortality and Date of Death are captured within Medical Claims as well as within a Master Death file – 30 different rates captured
- Complications – Avoidable complications of medical and surgical care are coded; measure overall complication rates as well as specific complications
- Days in Acute Care (DACs) – DACs are a measure of acute care days associated with an initial indexing event combined with DACs associated with “unplanned” return to acute care.
Evaluation of a new (network creation) or existing (network optimization) network across a framework of performance metrics, which may include:
- Standards of Access/Adequacy
- Affordability/Efficiency – based on both utilization patterns and unit cost
- Quality/Appropriateness of Care
- Accurate and Complete Condition Coding
- Health Equity
- Patient Experience
In order to drive the following outcomes:
- Lower cost for clients and members
- Enhanced clinical outcomes
- Higher revenue through accurate condition capture
- Increased member satisfaction/experience
- Drives strategic partnership opportunities with providers to jointly manage members and patients
- Reduces overhead cost tied to management of network
- Speed to Market in new Markets
Provider Claim Activity Indicators
This tool inspects the clinical activity of providers by specialty and geography based on categories of patient volume using all-payer claim information: Depending on the volume, providers are classified as Ghost (No patients), Peripheral (Bottom 25% percentile of patient volume), Standard (Middle 50% percentile of patient volume), and Core (Top 25% of patient volume). These indicators are available in total, and by specific lines of business.
Competitive Network Benchmarking
The benchmarking tool is an interactive dashboard that helps an organization understand how their network compares to their peers by Geography and Line of Business across multiple measures: Access, Demographics, and Performance.
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