An APCD Analytics Tool All Payer Claims Database APCD Eligibility medical claims pharmacy claims and provider files collected monthly Data submitted by commercial carriers and Medicaid no Medicare fee for service data ID: 698482
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3M Clinical Risk Groups (CRG)
An APCD Analytics ToolSlide2
All Payer Claims Database (APCD)
Eligibility, medical claims, pharmacy claims, and provider files collected monthly.
Data submitted by commercial carriers and Medicaid - no Medicare fee for service data.
3M Health Information Systems processes data semi-annually, adds enhanced elements (e.g. risk groupers), and returns database to OHCS.
2013 and 2014 data are currently available.Slide3
3M Clinical Risk Groups (CRG)
Designed to allow payers to reimburse providers who manage high-risk patients and to support accountable care and value-based purchasing.
Software assigns a patient to a mutually exclusive risk group based on their longitudinal claims history (including pharmacy claims).
Basically, the tool creates comparable groups (e.g. diabetes, hypertension, or diabetes with hypertension) and allows you to adjust for severity of illness within those groups (minor, moderate, major, or extreme).Slide4
3M Clinical Risk Groups (CRG)
Phase 1: A disease profile and history of past medical interventions is created. This profile consists of a set of diagnosis and procedural categories called Episode Diagnostic Categories (EDCs) and Episode Procedure Categories (EPCs).
Phase 2: For each organ system, the most significant chronic disease under active treatment, the Primary Chronic Disease (PCD), is identified and the severity of illness level of the PCD is determined.
Phase 3: The PCDs and associated severity of illness level along with the presence of other EDCs or EPCs are used to select the individual’s base CRG and assign the severity of illness level.Slide5
3M Clinical Risk Groups (CRG)
Phase 4: CRGs are consolidated into three successive tiers of aggregation called Aggregated Clinical Risk Groups (ACRGs).
Phase 5: Assign alternative risk adjustment models for prospective and concurrent applications.Slide6
CRG Analytics Tool
Microsoft Excel spreadsheet with pivot table
Grouper elements:
Base CRGs and ACRGs with descriptions and severity of illness
Patient demographics:
Age, gender and county
Counts
Allowed amounts
Inpatient, outpatient, professional, pharmacy, and total.Slide7
June Health Status UpdateSlide8
Live Demonstration
Talk about risky...Slide9
Questions?
A little less risky.Slide10
Training
In planning.
Contact
chawley@utah.gov
and send topics of interest.