Risk Assessment based on Medicare Utilization
Data released to the public by the Centers for Medicare and Medicaid Services detail the procedures performed by each physician as well as the amounts they were paid.
Because critical information, such as payer mix, diagnoses codes, patient acuity, etc., were not provided by CMS, using the raw values, such as total services or payments, are basically useless. Our tool has been designed to provide physicians with a real-world perspective on their Medicare billing activity. In order to both understand and benchmark your data, it first needs to be reduced to ratios, which is what we have done here. So, rather than try to compare total payments with that of your peers, it is much more valuable to look at total payments as a ratio of unique beneficiaries — a metric that is agnostic to payer mix and other important data points.
Have more than 50 providers? Send a list of your NPIs to firstname.lastname@example.org
For each metric, there are three columns.
- Under Physician are the data associated with the NPI number entered above.
- The Specialty comparative figures are the median values using all providers of the provider's specialty.
- The Variance column reports the variance of the physician to the specialty.
Each table contains ten rows of data, as follows:
- Unique Procedure Codes – is the number of unique HCPCS codes reported by the provider.
- Unique Patients – is the total number of unique patients reported by the provider.
- Total Services – is the total number of individual services (or line items and units) reported by the provider.
- Total Allowed – reports the total allowed amount assigned by CMS to the total services reported by the provider.
- Total Payments – reports the total amount paid by CMS to the provider.
- Paid to Allowed Ratio – is the ratio of the total paid amount to the total allowed amount. This number should equal or be close to 80% for most specialties.
- Services per Patient – is the ratio of the total number of services reported per unique beneficiary (patient).
- Services per Patient Percentile – This metric reports the percentile ranking for this provider compared to their peer group for the average number of services provided per unique patient. In our opinion, 75 to 90 (75th percentile to 90th percentile) represents a moderate risk while 90 to 100 (90th percentile to 100th percentile) represents a high risk.
- Payments per Patient – is the average amount paid to the provider per unique patient.
- Payments per Patient Percentile – This metric reports the percentile ranking for this provider compared to their peer group for the average paid amount per unique patient. In our opinion, 75 to 90 (75th percentile to 90th percentile) represents a moderate risk while 90 to 100 (90th percentile to 100th percentile) represents a high risk.