Medical Data Management Reporting
- Participating Physician Groups (PPG)
Information is gathered through the Health Net Utilization Management System (Unity) and claims system (ABS) to develop UM reports for each participating physician group (PPG) and Health Net internal staff. Initial reports include standard UM information (for example, average length of stay (ALOS) and bed-days per thousand members per year). This information assists in managing the provision of medical services.
Health Net monitors the effectiveness of plan-wide UM programs through the following reports:
- The inpatient census and detailed claims reports provide utilization information on the number of inpatient admissions, skilled nursing facility (SNF) admissions, emergency room visits and outpatient surgeries on a monthly, year to date, rolling 12-month and calendar year basis. This report gives UM staff and PPGs the ability to compare and manage hospital days in relation to the network benchmarks set at the 25th, 50th and 75th percentiles
- Hospital services are described and assessed through several individual reports, which provide performance measures for patients by assigned PPGs and for patients in the aggregate Health Net membership. Key metrics for each admission are reported for the month in which the patient was admitted. Each hospitalization is classified by service category Analytic Terminology Of Service code (ATOS) and DRG. The key metrics for each ATOS code or DRG include the total admissions, average length of stay, total bed days and total billed charges
- The 30-Day Re-Admits Report identifies inpatient re-admissions to any facility for any diagnosis within 30 days of a patient's discharge from an acute facility. This report is PPG-specific. It is run monthly and tracks trends over multi-month and multi-year intervals. The report criteria includes admissions to any facility for any diagnosis within 30 days of discharge from an acute facility. A subset of this report measures acute hospital (re)admissions from the SNF
- The 30-Day Re-Admits by Primary Care Physician (PCP) Report is similar to the 30-Day Re-Admits Report, but all utilization information is related to the member's PCP