Provider Cost and Quality Transparency Initiatives

We provide provider cost and quality evaluations and analysis for Medicaid plans such as:

Physician provider profiling to identify cost and quality patterns:

  • Top prescribers overall and within specialty groups by standard deviation groups for number of prescriptions, total number of patients and number of uncoordinated care patients, total cost, and cost per prescription compared within other specialist and general practice prescriber groups
  • Geographical mapping of all prescribers and outlier prescribers by specialty and identified problem issue at the regional, county, facility or zip code level
  • Top prescribers for specialized use drugs and narcotics to asses appropriate dosing, frequency and quantity of drug prescribed related to patient diagnoses and use of other concurrent drugs
  • Identification of physicians not consistent with HEDIS measures or national treatment guideline prescribing behaviors for various conditions such as antibiotic over usage, lack of inhaled steroid for asthma patients etc.

Pharmacy provider profiling to identify cost and quality patterns:

  • Top pharmacies by total number of prescriptions, total number of patients and number of uncoordinated care patients, total cost, high cost patients, total cost for specific classes or subclasses of drugs (i.e. specialized high cost drugs, narcotics etc), suspect billing patterns indicative of fraud and abuse
  • Geographical mapping of all pharmacies and outlier pharmacies by specialty type (infusion, community) and identified problem issue at the regional, county, facility or zip code level
  • Identification of paid claims with dates of service post patient’s date of death
  • Identification of incorrectly paid amounts or duplicate paid claims for the same patient, same drug, and same dates of service
  • Identification of pharmacies with patients that have low adherence rates for chronic disease medications to institute a medication therapy management program to promote increased adherence

Hospital emergency room provider profiling:

  • For facilities with highest rate of ER visits, highest number of patients with high frequencies of ER visits, highest rate of avoidable ER visits, highest cost per visit and by diagnosis, highest rates of chronic disease related visits, trauma visits, substance abuse visits and other various types of visits
  • Geographical mapping of all ER facilities and outlier facilities by identified problem issue at the regional, county, facility or zip code level