4.7 Diagnosis Analysis
Claims Review includes two reports that provide analysis based on the diagnostic
information included in claims:
Diagnosis Analysis and
Both reports are based on the International Classification of Diseases
(ICD) diagnosis coding system and provide a set of categories made up of
multiple ICD code ranges.
Code ranges for both diagnosis and lifestyle categories may be customized. Please see ICD9 Code Set section.
The graph displays how much the Plan Sponsor (green) and member (yellow) paid as well as the amount of savings obtained through network discounts (blue); the top of each bar represents the total original charge billed by providers. The numbers along the bottom of the graph can be matched back to the number (#) column in the table.
**Note that clicking on a specific diagnosis category drills down for further claims investigation. Please refer to the Drill Down section.
#: Diagnosis category number along the bottom of the graph can be matched back to the number (#) column in the table.
Category: Based on ICD9 diagnosis codes and set in categories made up of multiple ICD code ranges. Hovering over bold diagnosis category with cursor will provide ICD ranges(s) for that specific category.
# Claimants: The number of individual members that incurred claims.
- Total Charge: Original total amount billed by provider before any network or other claim payment consideration. More.
- Plan Paid: Total amount paid by Plan Sponsor.
- % Paid: The percentage of original billed charges paid by the plan sponsor. More.
- % Usage: The percentage of total dollars paid by the Plan sponsor. This is a measure of how much of total plan payment went to a specific item and is a useful indicator of how plan dollars are distributed between network and non network. More.
These reports can be used to assess the viability of disease management or wellness programs.
The covered population's proneness to morbidity can have a major impact on overall plan performance. The Diagnosis Analysis charts the distribution of cost across high level diagnosis categories allowing for claimants to be monitored.
Case Management nurses can drill down into diagnosis of concern. Information will help monitor claimant regimen to provide assistance in Disease Management Programs.
Aides Case Management nurses with an ongoing weekly/monthly tool for proactive approach on large claimants.
Headers (Diagnosis category, # Claimants, Total Charge, Plan Paid, % Paid and % Usage) can be manipulated by clicking on the desired report header to create additional reporting outcomes.