There are a lot of diagnosis distractions that can obscure what is really going on with high-dollar medical claims. Today’s lookback blog, High-Dollar Claimant Review: Inside the Doctor’s Brain, looks at how important it is to separate the wheat from the chaff when evaluating medical claims.
Compass receives medical claims feeds for employer clients, allowing us to analyze high-dollar claims based on diagnosis code and cost. As a result, I review a lot of high-dollar medical claims for self-funded employers.
Many employers and benefits consultants are not given enough detail about the high-dollar claims that are driving 60+ percent of a group’s claims spend. That is a real shortcoming.
Below are some examples of high-dollar claims and a brief translation of what these diagnosis codes and costs mean.
|Abdmnal pain generalized||$372.61|
|Abdmnal pain unspcf site||$976.86|
|Abn CNS funct study NEC||$1,039.28|
|Altered mental status||$2,246.76|
|Brain conditions NEC||$52.04|
|Chest pain NOS||$11.11|
|Depressive disorder NEC||$62.83|
|Duodenitis w/o hmrhg||$445.87|
|Fit/adj vascular cathetr||$20.78|
|Head & neck symptoms NEC||$32.34|
|Idiopathic normal press hydr||$1,102.02|
|Intestinal disorders NEC||$110.11|
|Intestinal obstruct NOS||$224.118|
|Malaise and fatigue NEC||$290.46|
|Malfun neuro device/graf||$10,243.10|
|Malfunc vasc device/graf||$32,664.69|
|Migrne wo aura wo ntrc mgrn||$299.87|
|Nausea with vomiting||$124.10|
|No inf gastroenterit NEC||$3,863.41|
|Other postop infection||$434.05|
|Other specified aftercare||$16.59|
|Pleural effusion NOS||$947.18|
|Preop cardiovasclr exam||$11.50|
|React-nerv sys dev/graft||$1,943.50|
|React-oth vasc dev/graft||$50,029.30|
|Rehabilitation proc NEC||$10,728.00|
|Ventricular shunt status||$183.32|
The member has a condition called hydrocephalus (too much fluid around brain), which is treated by placing a tube from the brain to the abdomen (called a VP shunt). This shunt got infected and had to be surgically removed. This condition is the result of bad luck or sub-optimal care or both. There will likely be ongoing claims.
Employers and benefits consultants will want to know if the high-dollar claimant is going to continue generating significant healthcare costs. Some high-dollar claimants are ‘flashes in the pan,’ and their issue is resolved and ongoing claims will not continue. Other high-dollar claimants will continue to have a lot of expensive claims. For budgeting and intervention purposes, population health managers (i.e. employers and benefits consultants) will want to know which is which.