This report provides a breakdown of member months, revenue, expenses, adjustments and IBNR by one or more Fund Types.  These numbers are aggregated by Entity.  The categories are then used to calculate Medical Loss Ratio (MLR), Revenue PMPM and Expense PMPM.  It also shows Peer comparisons, where available.  The total population can be filtered by the three main system filters, as well as multiple page filter options.

Target Audience for this Report

Finance Department and CFO, Chief Medical Officer, Leadership Team.

Business Processes Impacted by this Report

This report will allow for the target audience to view membership, revenue, costs and MLR at a macro level to evaluate how the plan is doing by comparing the ratio of expenses to revenue.

Medical Loss Ratio table:

Line items are by defined Fund Types for the plan and columns represent the financial component of the fund type.  


Details and Definitions


Fund Type – Allows for expenses to be categorized at a line level.  Example: Part A and Part B expenses and revenue can be broken out on separate line levels to track individually.  These line level categories are defined by the Entity.


Member Months – The total number of member months for the time period.  If the plan has 5,000 members and the time period selected in from January 2016 to March 2016 (3 months) the Member Months = 15,000


Funding – This is the total amount of revenue, premium or funds available for this Entity for the time period.


Capitation Expense – This is the total amount of capitated expenses that the Entity has paid for during the time period.  Capitated expenses are services contracted out to third parties, usually on a per member per month basis.  Primary Care, Behavioral Health and Lab services are examples of capitated expenses.


Claims Expense – This is the total amount of fee for service claims that the Entity has paid out to providers for the time period.


Manual Adjustment – This is the total amount of financial adjustments that have been made in order to balance the revenue and expense columns.


IBNR Expense – Incurred But Not Reported amount that is calculated by the Entity to serve as an estimated completion factor for services that have not been processed.


Total Expense – The sum of all expense columns.


Fund Balance – This is the amount of funding available after the total expenses have been subtracted.


MLR % - Medical Loss Ratio % is the calculated value of the ratio of the total expenses divided by total funding (revenue), represented in a percent format.


PMPM – Per Member Per Month is the calculation of a total sum of expenses or funding (revenue) divided by the Member Months.  This value is represented in a dollar format.


Medical Loss Ratio KPIs

A graphical representation of:

  • Funding PMPM
  • Total Expense PMPM
  • Fund Balance PMPM
  • MLR %