medical claims data in life underwriting280.9: iron deficiency anemia medications billed to major...
TRANSCRIPT
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June 6, 2019ACTUARIES' CLUB OF THE SOUTHWESTJenna Fariss, ASA, MAAA
Medical Claims Data in Life Underwriting
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Agenda
What is Medical Claims Data?
Examples
Best Practices
How Does Medical Claims Data Work?
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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
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What is Medical Claims Data?
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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.
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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
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Medical Claims Data shows what was done (CPT) and why it was done (ICD).
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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
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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
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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
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Prescription Data Can Compliment Medical Claims Data
Type 1 Type 2 Unspecified
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Prescription Data Can Compliment Medical Claims Data
Type 1 Type 2 Unspecified
Insulin-dependent diabetes:Relative Mortality: 307%
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Type 2 Diabetes is common and complicated.
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Medical Claims Data helps you determine severity and provide clarity.
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Focus on relevant data.
Procedure:CPT code 70450: Head CT with Contrast
Diagnosis:ICD-10 code R51: Headache
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Focus on relevant data.
Procedure:CPT code 70450: Head CT with Contrast
Diagnosis:ICD-10 code R41.82: Altered Mental Status
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Focus on relevant data.
Procedure:CPT code 70450: Head CT with Contrast
Diagnosis:ICD-10 code I63: Cerebral Infarction
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Example: 51 year old Female, SI Policy – Rx Only
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Medical Claims Data View
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Medical Claims Data View continued
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Another Example Prescription Data
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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
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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
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Sample Case – Original Data
Final ExpenseAge: 49 | Gender: FOriginal Rx Query: 10/25/16Prescriptions Filled: 31
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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
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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
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Thank you!Jenna Fariss, ASA, MAAA
Product Consultant, Medical Data