Embed Size (px)
Citation preview
June 6, 2019ACTUARIES' CLUB OF THE SOUTHWESTJenna Fariss, ASA, MAAA
Medical Claims Data in Life Underwriting
Agenda
What is Medical Claims Data?
Examples
Best Practices
How Does Medical Claims Data Work?
The Future of Underwriting
Electronic requirements (Rx, MIB, MVR, Medical, Consumer …)
Decision engines driven by data
Predictive Models
Automation
Increasing
APS, Labs
Cycle times
Costs
Decreasing
Better Customer Experience
What is Medical Claims Data?
1
2
3
Query data sources in real time FCRA compliant – 7 years of data
Obtain applicant’s claim data from recent medical encounters Diagnosis codes (ICD 9 / 10) Procedure codes (CPT) Durable medical equipment codes (HCPCS) Inpatient / clinic-administered medications (HCPCS) Provider, encounter information
Supplements traditional underwriting data Application data, Rx, APS, MIB, MVR, etc.
There’s a code for THAT?! ICD-10 Coding
Y93.17: Activity, water skiing and wake boarding
V91.07XA: Burn due to water skis on fire, initial encounter
6
Medical Claims Data shows what was done (CPT) and why it was done (ICD).
Provider data including NPI
Treatment dates
Diagnosis Codes 585.5: Chronic Kidney Dz, Stage V 274.11: Uric Acid Nephrolithiasis 280.9: Iron Deficiency Anemia
Medications billed to major medical J2501: paricalcitol J2916: sodium ferric gluconate J3370: vancomycin HCl
Other procedures billed to major medical Labs and other procedures Durable medical equipment
Dialysis Claim Example
Surgery Claim Example
Medications billed to major medical J2405: Ondansetron injection J2765: Metoclopramide injection
Provider data including NPI
Hospitalization or Treatment dates
Diagnosis Codes 553.21: Incisional hernia
Procedures billed to major medical C1781: Mesh (implantable) 88302: Surgical pathology level 2 49568: Implantation of mesh 49560: Repair incisional hernia
Medical Claims Data can identify risk when there is no Rx treatment.
Drug/AlcoholServices
H0005-HCPCSAlcohol and/or drug services;
group counseling by a clinician
H0015-HCPCSAlcohol and/or drug services;intensive outpatient treatment
Prescription Data Can Compliment Medical Claims Data
Type 1 Type 2 Unspecified
Prescription Data Can Compliment Medical Claims Data
Type 1 Type 2 Unspecified
Insulin-dependent diabetes:Relative Mortality: 307%
Type 2 Diabetes is common and complicated.
Medical Claims Data helps you determine severity and provide clarity.
Focus on relevant data.
Procedure:CPT code 70450: Head CT with Contrast
Diagnosis:ICD-10 code R51: Headache
Focus on relevant data.
Procedure:CPT code 70450: Head CT with Contrast
Diagnosis:ICD-10 code R41.82: Altered Mental Status
Focus on relevant data.
Procedure:CPT code 70450: Head CT with Contrast
Diagnosis:ICD-10 code I63: Cerebral Infarction
Example: 51 year old Female, SI Policy – Rx Only
Medical Claims Data View
Medical Claims Data View continued
Another Example Prescription Data
TimelineTrastuzumab (HER2+):
07/09/2017
Carboplatin,Paclitaxel,
Pertuzumab:07/09/2017
ER negative status:10/05/2017
Mastectomy simple complete,Mastectomy modified radical:
11/08/2017
Looking again further enhances the underwriting process.
Identifies significant new medications / conditions since application
Flags potential misrepresentation early within the contestable period
Avoids costly investigation and legal issues at claim time
Clearly identifies specific cases to investigate
Sample Case – Original Data
Final ExpenseAge: 49 | Gender: FOriginal Rx Query: 10/25/16Prescriptions Filled: 31
Sample Case – Looking again with Medical Claims Data
Final ExpenseAge: 49 | Gender: FOriginal Rx Query: 10/25/16Looking Again Dx Query: 8/16/17
Probable Condition Days Before QueryLiver Cancer 12
Best Practices for interpreting Medical Claims Data.
Focus on relevant data (ignore “noise”)
Funnel codes to therapeutic categories
Identify Rx and Medical Claims Data combinations
Facilitate underwriting decisions
Thank you!Jenna Fariss, ASA, MAAA
Product Consultant, Medical Data
