IntelliRisk Advanced. Report Samples Guide

Transcription

1 IntelliRisk Advanced Report Samples Guide

2 Published by AIG IntelliRisk Services 5 Wood Hollow Road, 3 rd Floor Parsippany, NJ Copyright 2009 American International Group, Inc. All Rights Reserved. No part of this publication (including interior design, cover design, and illustrations) may be reproduced or transmitted in any form, by any means, (electronic, photocopying, recording, or otherwise) without the prior written permission of the publisher. IntelliRisk Advanced Report Samples IntelliRisk is a registered trademark of American International Group, Inc. Excel is a registered trademark of Microsoft Corporation.

3 Report Description and Table of Contents Claims... 1 AIG Standard Loss Run...1 Calendar Year Summary...1 Lag Time...1 Loss Summary...2 Monthly Payment...2 Risk Detail...2 Risk Detail Summary by Line of Business...3 Litigation... 3 Claims in Suit...3 Closed Suits by State...3 Loss Control... 4 Loss Control...4 Repeater...4 Managed Care TCM/UM... 4 Field Based Case Management...4 Telephonic Case Management (TCM) Cumulative Report...5 Telephonic Case Management (TCM) Snapshot Report...5 Utilization Management...5 Managed Care/Bill Review... 6 Bill Types Processed...6 PPO/PBA Savings...6 PPO Penetration...6 Top Twenty Medical Providers...6 Managed Care/Lost Time/RTW Reports... 7 Lost Time Claims Only RTW...7 Return to Work by Location (RTW)...7 Managed Care/Pharmacy Reports... 7 Pharmacy Benefit Management (PBM)...7 Pharmacy Benefit Management Savings Summary...7 Pharmacy Home Delivery Savings Summary...8 Pharmacy Online Savings Summary...9 Pharmacy Payee...9 directdme Savings...10 Point in Time/Excel Reports Point in Time - Claim Level Account Detail...10 Point in Time - Claim Level Account Summary...10 Point in Time - Symbol Level Account Detail...11 Point in Time - Symbol Level Account Summary...11 Valuation Comparison Valuation Comparison Detail...11 Valuation Comparison Summary...12

4 Report Samples AIG Standard Loss Run Calendar Year Summary Lag Time Loss Summary Monthly Payment Risk Detail Risk Detail Summary by Line of Business Claims in Suit Closed Suits by State Loss Control Repeater Field Based Case Management Telephonic Case Management (TCM) Cumulative Telephonic Case Management (TCM) Snapshot Utilization Management Bill Types Processed PPO/PBA Savings PPO Penetration Top Twenty Medical Providers Lost Time Claims Only RTW Return to Work by Location (RTW) Pharmacy Benefit Management (PBM) Pharmacy Benefit Management Savings Summary Pharmacy Home Delivery Savings Summary Pharmacy Online Savings Summary Pharmacy Payee directdme Savings Point in Time Claim Level Account Detail Point in Time Claim Level Account Summary Point in Time Symbol Level Account Detail Point in Time Symbol Level Account Summary Valuation Comparison Detail Valuation Comparison Summary... 45

5 Claims AIG Standard Loss Run This is an abridged version of the Risk Detail Report. Subtotals by Account, Policy Number and Levels 1-6 (if selected) are provided, with a Report Summary by Client, Account, Policy Number and Line of Business at the end of the report. Workers Comp claims also have totals by Loss Type (Med Only, Indemnity, and Notice). Totals are provided for the number of claims (symbol level) by policy number, claim status and financials by current payments, paid, reserves, recoveries and incurred. The easier to read format of this report provides a comprehensive picture of losses in a more manageable report. Summary totals assist in analyzing the frequency and severity within specific categories, including location coding, if selected. Calendar Year Summary The Summary by Calendar Year Reports summarize claims by Calendar year for a user defined parameter including: by Accident State, Benefit State, LOB, Loss Type, Level 1, Level 2, Level 3, Level 4, or by Loss Stratification by Incurred Total. All claims for the current year plus the prior 4 years will be included, unless otherwise specified by the user. This report allows for the comparison of frequency and severity from one calendar year to another. It provides the ability to analyze the data by any one of 9 different parameters. This report is a useful tool for reviewing and analyzing the progression of the overall program which may be helpful in identifying areas needing improvement and estimating future costs. Lag Time The Lag Time Report is a detail report that calculates the lapsed time between 3 key dates during the reporting process - the number of days between the Loss Date and The Employer Notification Date, between the Employer Notification Date and the Reported (to AIG) Date, and between the Loss Date and the Reported Date. A summary section provides totals and percentages by number of day groupings for the 3 lag time periods. Useful in tracking timeliness of claim reporting and the possible need to improve or implement claims reporting procedures, conduct training, etc. 1

6 Loss Summary The Loss Summary Report provides the ability to report on Policies, Level 1 or Level 2 that have no losses in a format similar to the Risk Detail Summary report. The user may choose a 2 nd parameter to indicate the display options for the report, that is - ZERO ONLY, INCLUDE ZERO, or SUPPRESS ZERO. No losses as defined in this report is based on claim counts, not financials. Even though there are 4 filters listed in the Available Filters list, when using the Zero Only or Include Zero parameters, only the filters that pertain to the parameter chosen in the 1 st parameter box will apply, i.e.: if Policy is chosen, the Policy # or Policy Year filter may be applied, for Division, only the Division filter may be applied, and for Location, the Location filter only. The Loss Summary Report is a summary report which allows the user to report on Zero Losses. This may be done by Policy, Level 1 or Level 2. The user may choose to see only Zero losses, include zeros, or may suppress zeros. Monthly Payment The Monthly Payment report displays detailed payment information for the prior month period (including Payee Name, Payment Amounts and Minor Code Descriptions) as well as claim detail (including Claimant Name, Claim Number, Loss Date, Loss Type, Status and Total Paid). A summary page is also provided. Three levels of roll-ups are available. The Monthly Payment is an excellent tool that can be used to reconcile billing and track monthly costs. Risk Detail This report provides detailed claim information and financial activity displayed in a multi-line format for each policy within an account. Financial loss data includes outstanding reserves, current payments and recoveries at a claim, policy and account level. Other non-financial details are included, i.e., claimant name, occupation, accident/injury descriptions, loss type and claim status. Totals are provided at the claim, location, policy, line of business, account and client levels. Detail information is provided on claims for the past 5 years (unless otherwise restricted or expanded by user defined filters), with summary information only on claims older than 5 years. The Risk Detail Report is an excellent resource for comprehensive claim detail, including current month payments. The ability to specify a point in time date, and roll-up by different levels of the location coding make this report a powerful analytical tool. 2

7 Risk Detail Summary by Line of Business This report summarizes claim information by Line of Business (within Client, Account, and Policy number Year) with claim counts and financials by Status. Totals are provided by LOB, Policy Year, and Account. A Client Summary is provided at the end of the report, summarizing by LOB, with claim counts and financials by Status, and a grand total for the Client. This report allows for high level analysis of frequency and severity, with access to totals by LOB and Policy Year. Litigation Claims in Suit This report lists all claims in suit, grouped by defense attorney, and sorts either by the Claimant Name or the Total Incurred. The defense attorneys are grouped by AIG Staff Counsel/Outside Counsel. Total numbers of suits handled are shown for the individual attorneys as well as totals for AIG Staff Counsel and Outside Counsel. The grand total of claims handled by both AIG Staff Counsel and Outside Counsel are provided at the end of the report. The report serves as a ledger of claims in litigation. Closed Suits by State This report summarizes closed suits by Method of Conclusion, within each State (where the suit was filed). It provides the average number of days suits were open, total legal paid, average legal paid, total incurred and average cost per claim, with totals for each state. A summary page at the end of the report provides grand totals for all states. This report may be used to analyze closed suits based on method of conclusion. 3

8 Loss Control Loss Control This report summarizes claims by user specified parameters, including: Body Part; Cause; Nature of Injury; Division; Location; Dept; Section; Tenure at Date of Loss; Accident State or Policy Year. It provides claim counts and % of claims (claim counts or symbol counts), as well as paid and incurred totals broken out by Average, Total, % of Total, and a Total Reserve. The report s drill down feature enables access to claim details for each claim summary. Financial loss summary by accident state, grouped by policy year and program coverage identifies where costs are incurred and frequency of claims occur. A useful tool for analyzing and identifying potential states/locations that may benefit from implementing new or revised safety programs, improvements in environment, workflow re-engineering, etc. to decrease severity. Repeater The Repeater Report is a detail report which captures claimants with multiple reported claims involving Workers Comp and Auto losses. The claims are matched solely by SSN, even though only the last four digits of this number are printed on the report, for security reasons. The Repeater report provides the ability to identify and analyze repeat offenders and utilize the information to improve environment or safety programs to reduce the reoccurrence of accidents. Managed Care TCM/UM Field Based Case Management The Field Based Case Management (FBCM) Report is used to track FBCM referral activity and compare recent activity to YTD activity. Average costs and savings are provided. Report may be summarized by Benefit State or Level 2. This is a useful tool to analyze, by level 2, claims that have been referred to case management. Current period referrals can be compared to YTD referrals, and average cost and savings are provided for closed claims. 4

9 Telephonic Case Management (TCM) Cumulative Report This report summarizes cases referred to telephonic case management for cost control. It lists cases by Status, (New, Closed or Pending) and provides the average number of days for cases to be referred to TCM as well as the percentage of overall medical only and indemnity claims referred for TCM. The report also shows the number of employees released to full or modified duty and the Return to Work count, and provides the average cost, average dollar savings, and average duration per case. The report may be summarized by Level 2 Code or Benefit State. The cumulative report updates itself over time and picks up late reporting from vendor companies. This report tracks the effectiveness of telephonic case management. Telephonic Case Management (TCM) Snapshot Report This report summarizes cases referred to telephonic case management for cost control. It lists cases by Status, (New, Closed or Pending) and provides the average number of days for cases to be referred to TCM as well as the percentage of overall medical only and indemnity claims referred for TCM. The report also shows the number of employees released to full or modified duty and the Return to Work count, and provides the average cost, average dollar savings, and average duration per case. The report may be summarized by Level 2 Code or Benefit State. The "snapshot" report shows a "fixed" snapshot of previous month-end. This report tracks the effectiveness of telephonic case management. Utilization Management This is a detail report, by Review Type, listing claims that have used case management. It provides the claim number, claimant name, ICD9 code and description, loss date, dates that MMC service was requested and completed, number of units (services or doctor visits) requested and approved, and utilization management fees and benefit savings. This report shows managed care intervention and savings on a claim by claim basis within review type. 5

10 Managed Care/Bill Review Bill Types Processed This report summarizes medical bills by type of bill, providing the amounts billed and paid fees, and savings amounts. Bills are summarized by network and non-network providers, and may be rolled up by Level 2 or Benefit State. This report provides a breakdown of costs by medical service provided and may be used to identify areas where costs may be reduced. PPO/PBA Savings This is a summary report, showing PPO and PBA savings, fees, and return on investments (ROI) as a result of medial bill audits. The report may be summarized by Levels 1-4 or Benefit State This report summarizes costs and savings derived from using Managed Medical Care services. PPO Penetration This is a summary report, showing the amount billed for a given period, and of that billed amount, how much was paid to PPO s (Preferred Provider Organizations). It also includes the number of new bills audited, and how many were network bills, and shows the percent of billed amount and bill count that was paid to PPO s. The report may be summarized by Levels 1-4, or Benefit State This report provides an analysis of PPO Penetration for the selected parameter (Level 1, Level 2, Level 3, Level 4, or Benefit State). Top Twenty Medical Providers This report lists the top twenty medical provider locations, either by number of bills audited or net billed amount. It is sorted by medical provider s state, type of bill and whether the provider is in or out of AIG s PPO network. The report includes provider tax ID, name and address, number of new bills audited, PPO and PBA savings, paid amount, total fees, total savings, and net savings. This report provides costs and savings by the provider location. 6

11 Managed Care/Lost Time/RTW Reports Lost Time Claims Only RTW This detail report shows Lost Time Days, RTW information and a total medical and indemnity paid on lost time claims. It also includes the location code hierarchy. Only workers comp claims with lost time days equal to or greater than 1 day are selected for this report. This report provides for tracking of claims with lost time days. Return to Work by Location (RTW) This detail report provides information on lost time claims. It includes dates released to modified or full duty, RTW date, lost time days, and total medical and indemnity paid. This report provides for tracking of lost time claims. Managed Care/Pharmacy Reports Pharmacy Benefit Management (PBM) The Pharmacy Benefit Management (PBM) Report summarizes pharmacy payments. Paid amounts are summarized first by total paid to pharmacies and total prescription reimbursements made to employees, along with a total number of payments. Payments are further broken down by type of PBM program Online PBM Program and Home Delivery PBM program with total paid and percentage paid within the PBM Program. Summary is by Benefit State or a level of the location coding, as selected by user. Payment period defaults to prior month, but user may specify a different period by choosing the Process Date Range filter. Data is available from 1/1/2004 forward. This report allows tracking of pharmacy payments as part of a cost control program. Pharmacy Benefit Management Savings Summary This summary report displays the total number of pharmacy scripts captured within the AIG Pharmacy Benefit Management Program (PBM) with focus on savings below state fee schedule or the usual and customary amounts (UCR) when a pharmacy bill is processed through the AIG PBM. 7

12 Outcomes are reported by either benefit state or insured location structure for a requested reporting period. Payment period defaults to prior month, but a different period can be specified by choosing the Process Date Range filter. Data is available from 1/1/2006 forward. Savings are further broken down by type of PBM savings Online, Home Delivery and Blocked Savings. The AMOUNT PHARMACY BILLED column summarizes the amount that AIG would pay at state fee schedule or UCR amounts prior to PBM program savings being applied to each script processed. The FEE SCHEDULE / UCR SAVINGS column summarizes the total amount that AIG paid thru the PBM program after PBM savings are applied to each transaction further broken out by savings types: ONLINE SAVINGS summarizes the amount saved below the amount the pharmacy billed when the pharmacy bill is processed online between our PBM and a retail pharmacy location. HOME DELIVERY SAVINGS summarizes the total amount saved through use of the PBM home delivery program. BLOCKED SAVINGS are captured as a script is blocked from being processed within the PBM and stays blocked for 45 days. This report allows tracking of overall pharmacy savings and utilization as part of the AIG PBM cost control program. Pharmacy Home Delivery Savings Summary This summary report displays the number of pharmacy scripts processed as a mail order home delivery directly to the injured employee with a focus on savings captured below state fee schedule or the usual and customary amounts (UCR). Outcomes are reported by either benefit state or insured location structure for a requested reporting period. Payment period defaults to prior month, but a different period can be specified by choosing the Process Date Range filter. Data is available from 1/1/2006 forward. The AMOUNT PHARMACY BILLED column summarizes the amount that AIG would pay at state fee schedule or UCR amounts prior to home delivery savings applied to each script processed. The AMOUNT ALLOWED column summarizes the amount that AIG paid thru the home delivery PBM program. The PHARMACY SAVINGS column displays the amount saved below the fee schedule or UCR when the home delivery PBM is used. 8

13 This report allows tracking of pharmacy savings and utilization for home delivery within the overall AIG PBM cost control program. Pharmacy Online Savings Summary This summary report displays the number of pharmacy scripts processed as an online transaction between a pharmacy retailer and the AIG PBM with a focus on savings captured below state fee schedule or the usual and customary amounts (UCR). Outcomes are reported by either benefit state or insured location structure for a requested reporting period. Payment period defaults to prior month, but user may specify a different period by choosing the Process Date Range filter. Data is available from 1/1/2006 forward. The AMOUNT PHARMACY BILLED column summarizes the amount that AIG would pay at state fee schedule or UCR amounts prior to an online pharmacy transaction. The AMOUNT ALLOWED column summarizes the amount that AIG paid through the online PBM program. The PHARMACY SAVINGS column displays the amount saved below the fee schedule or UCR when the online PBM program is used. This report allows tracking of pharmacy savings and utilization for online pharmacy transactions within the overall AIG PBM cost control program. Pharmacy Payee This report summarizes pharmacy payments by the most frequently used prescription services providers (user specified up to 20 vendors). The payments for the current period are compared to the same period one year prior, with a Total RX Paid, and a % of the total paid for each period. Report is sorted in descending sequence by Total RX Paid for the most current period. Payment period defaults to prior month, but user may specify a different period by choosing the Process Date Range filter. Data is available from 1/1/2004 forward. This report only shows pharmacy payments and lets the user compare time frames of choice and allows you choose how many vendors you wish for your report. 9

14 directdme Savings The directdme Savings Report displays the total number of durable medical equipment (DME) invoices captured within the directdme program with a focus on savings below state fee schedule or the usual and customary amounts (UCR). Outcomes are reported by either benefit state or insured location structure for a requested reporting period. Payment period defaults to prior month, but user may specify a different period by choosing the 'Process Date Range' filter. Data is available from January 1, 2009 forward. Savings are further broken down by savings type: Network; Intervention; and Blocked Savings. This report shows savings not usually seen, the savings over fee schedule and UCR, as part of the overall AIG PBM cost control program. Point in Time/Excel Reports Point in Time - Claim Level Account Detail This Excel report contains approximately 40 fields of claim and financial data. The Claim Level reports roll up all symbols on a claim. This is a point in time report (user may specify the as of valuation date). This report is an excellent tool for in-depth analysis due to the ability to retrieve the data as of different points in time, with the ability to analyze the data in Excel. Point in Time - Claim Level Account Summary The Claim Level Account Summary report is an Excel report that summarizes claims by Policy Year, LOB and Loss Type. All symbols will roll up and count as one claim. This is a point in time report (user may specify the 'as of' valuation date). The Claim Level Account Summary report is an excellent tool for in-depth analysis at a summary level due to the ability to retrieve the data as of different points in time, and being able to analyze the data in Excel. 10

15 Point in Time - Symbol Level Account Detail The Symbol Level Account Detail report is an Excel report containing over 40 fields of claim and financial data. This is a point in time report (user may specify the as of valuation date) The Claim Level Account Detail report is an excellent tool for in-depth analysis due to the ability to retrieve the data as of different points in time, and being able to analyze the data in Excel. Note: A Full Version of this report, which includes a Social Security Number field, also is available. Point in Time - Symbol Level Account Summary The Symbol Level Account Summary report is an Excel report that summarizes claims by Policy Year, LOB and Loss Type. This is a point in time report (user may specify the as of valuation date). The Symbol Level Account Summary report is an excellent tool for in-depth analysis at a summary level due to the ability to retrieve the data as of different points in time, and the ability analyze the data in Excel. Valuation Comparison Valuation Comparison Detail The Valuation Comparison Detail Report compares detail claim information for 2 points in time (2 month-end dates). Total Incurred, Total Paid, and the Status are given for each month-end period. A Total Incurred Percent Change and a Total Paid Percent Change are calculated and displayed. This report can be burst by the parameter selected from the 1st roll-up box (Level 1 Code, Level 2 Code, Level 3 Code, Level 4 Code, LOB, Loss Type, Pol Number, Pol Yr). A burst report must be sent via , with a distribution list based on the selected parameter. This report will allow the user to view total incurred, total paid, and claim status for all claims as of a specified valuation date and compare the accompanying values to those at another user specified time. This report can be used to monitor claim progress and may be used as a potential claims forecasting tool. 11

16 Valuation Comparison Summary The Valuation Comparison Summary Report compares summary information based on 2 points in time (2 month-end dates). Total Incurred, Total Paid, and Claim Count are given for each month-end period. A Total Incurred Percent Change and a Total Paid Percent Change are calculated and displayed, along with claim counts for status changes (for example, Number of claims that changed from Open to Closed). This report will allow the user to view total incurred, total paid, and claim status for all claims as of a specified valuation date and compare the accompanying values to those at another user specified time rolled up by a user specified parameter. This report can be used to monitor claim progress and may be used as a potential claims forecasting tool. 12

17 AIG Standard Loss Run Back to Description 13

18 Back to Description Calendar Year Summary 14

19 Back to Description Lag Time 15

20 Loss Summary Back to Description 16

21 Monthly Payment Back to Description 17

22 Risk Detail Back to Description 18

23 Back to Description Risk Detail Summary by Line of Business 19

24 Back to Description Claims in Suit 20

25 Back to Description Closed Suits by State 21

26 Back to Description Loss Control 22

27 Back to Description Repeater 23

28 Back to Description Field Based Case Management 24

29 Back to Description Telephonic Case Management (TCM) Cumulative 25

30 Back to Description Telephonic Case Management (TCM) Snapshot 26

31 Back to Description Utilization Management 27

32 Bill Types Processed Back to Description 28

33 PPO/PBA Savings Back to Description 29

34 Back to Description PPO Penetration 30

35 Top Twenty Medical Providers Back to Description 31

36 Back to Description Lost Time Claims Only RTW 32

37 Return to Work by Location (RTW) Back to Description 33

38 Back to Description Pharmacy Benefit Management (PBM) 34

39 Back to Description Pharmacy Benefit Management Savings Summary 35

40 Back to Description Pharmacy Home Delivery Savings Summary 36

41 Back to Description Pharmacy Online Savings Summary 37

42 Back to Description Pharmacy Payee 38

43 Back to Description directdme Savings 39

44 Point in Time Claim Level Account Detail Back to Description 40

45 Back to Description Point in Time Claim Level Account Summary 41

46 Point in Time Symbol Level Account Detail Back to Description 42

47 Point in Time Symbol Level Account Summary Back to Description 43

48 Valuation Comparison Detail Back to Description 44

49 Valuation Comparison Summary Back to Description 45

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