Not collecting control totals is as smart as 🤹♂️ juggle chainsaws while riding a 🚲 unicycle on a tightrope over a pit of hungry 🐊 alligators.
However, many companies have not implemented this fundamental check for incoming datasets.🤦♂️🤦♂️🤦♂️
Attached is a list of Key QC Checks for Medical and Pharmacy data. What other key checks should be added?
Key QC Checks for Medical and Pharmacy Claims Data Note: All checks and metrics listed below apply to both Medical and Pharmacy Claims data.) • Control Totals - (🤦♂️Stop here if you're not collecting from external sources🤦♂️) • Does data align to layout and field value requirements • Determine Granularity of Data: Last Version, All Versions...etc. • Determine if In-process claims are included • Define the unique key of your data • Duplicate Records Check • Number of Claims by month (matrix of paid month vs service month) • Allowed Amount by month (matrix of paid month vs service month) • PMPMS (Per Member Per Month Spending) • Outlier Claims • Number of eligible members by month • Number of distinct members with claims by month • Number of distinct members with claims vs total eligible members by month • Benchmarks - Comparison of results to other datasets and deliverables • Benchmarks - Compare pricing to CMS (Centers for Medicare and Medicaid Services) • Range of Dates of Service (Medical and Pharmacy) • Range of Paid Dates (Medical and Pharmacy) • Types of reimbursement: FFS, Bundles, Capitation, Per Diem…etc. • Are there pharmacy claims for Self-Insured Members/LOBs?
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