Medicare Claims Data Sources & Use Cases

Some specific use cases for care management:

1.??????Probability of High-Cost Patient Encounter:?The probability of a hospital or emergency visit encounter during the current year using claims data to run a probability model based on risk scores, diagnoses, and other historical data.

2.??????Medication Adherence:?The probability of a medication adherence encounter during the current year using claims data to identify a) drugs prescribed, picked up once, and not picked up again; and b) drug not prescribed but patient has a diagnosis correlated to maintenance medications.

3.??????Out-of-Network Encounters:?Review patient’s out-of-network encounters to redirect the patient to care-managed in-network providers if applicable.?

Book an appointment with me to discuss additional use cases.

Kris Gates, [email protected]