MMA Blog

Garbage In, Garbage Out

As lead of the MMA Population Health Management and Informatics Department I deal with a lot of data: medical claims, pharmacy claims, biometrics, health assessments, disability, workers compensation, etc. Our MMA clients deserve accurate data to help them with risk mitigation strategies and rely on MMA consultants to provide reports to better manage their business. One of my biggest challenges is being sure the data we collect and report is accurate. Without a team of data experts who can scrub the data, clean it, evaluate it for plausibility, compare it to trend and to norms I would tell you to never trust a report you receive from anyone, especially your carrier, a consultant and/or especially any vendor. Let me give you some examples of how garbage in is garbage out.

Scenario #1

The data warehouse that receives and processes all your medical and pharmacy claims data didn't realize you had a carrier change, so not only does your report not include run out data it is missing run in data from the new carrier or PBM.

Scenario #2

You carrier sends all your data to your broker/consultant in an aggregated manor but since the PPO data platform is different from the High Deductible data platform the carrier forgets to send the High Deductible data. Now your reports are missing the 10-20% of members financial data on the High Deductible plan, even though the member count in the eligibility file is correct, thereby throwing off all the reported PMPMs by 10-20%.

Scenario #3

Your carrier moves from their old legacy claim processing system to a new national platform which significantly changes how data is transmitted and recorded. For example: your carrier's new claim processing system no longer provides a place of service (POS) code throwing off the in-patient, outpatient, ER and office PMPM's from one period to another.

Scenario #4

Since there is no accepted definition of what a "drug" is, every time you change PBMs, your generic fill rate percentage changes and you wonder why.

Scenario #5

You change your carrier and because the eligibility file from your old carrier is inconsistent with the eligibility file from your new carrier, members are counted twice throwing off member months, PMPM's and all utilization metrics.

The above scenarios are real, have happened, been caught and corrected before any reports go out, but unless you have confidence someone is looking under the covers at how the data is pulled, aggregated, scrubbed and the data is PLAUSIBLE, based on historical trend and industry norms then you should be very skeptical. In today's digital world we have a wealth of data and very little factual information because a lot of what we see is a result of garbage in, garbage out.

From the desk of: Dr. Rearick, Chief Medical Officer, MMA Mid-Atlantic 

P.S. Don't trust anything you read on the Internet without checking it out. Go to Scopes.com or TruthorFiction.org for urban legends, folklore, myths, rumors and misinformation. Try FactCheck.org for political fact checking.

Posted September 30, 2014

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