Overview
This report provides a breakdown of member months, revenue, expenses, adjustments and IBNR by one or more Fund Types at the Provider Group level. Selecting a Provider Group will allow for displaying detailed Provider Group information, as well as Provider Group vs Peer comparisons. 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 from and to period, 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 Provider Group level. This allows the plan to review how individual Provider Groups are impacting the total MLR. This information can be used to identify Provider Groups that need additional training, or Provider Groups that are performing well and need to be studied.
MLR by Provider Group
Line items are by defined Provider Groups and columns represent the financial component of the Provider Group. Selecting a Provider Group will display peer comparisons in the Medical Loss Ration Graphs and Fund Type level detail in the Provider Group Details table.
Details and Definitions
Provider Group – A group of providers that associated by either a Federal Tax Identification Number or a
NPI.
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.
MLR by Provider Group (table)
This table shows all Provider Groups, based on the applied filters, and the aggregated column amounts. This table is a multi-select table. The first Provider Group selected will continued to be displayed in the Provider Group by Fund Type table and be represented by a line in the Group Comparison graph. Subsequent selections can be made by holding the Control key down and clicking on other Provider Groups. At this point all subsequently selected Provider Groups will be represented as a separate line on the Group Comparison graph.
Provider Group (column 1) – Provider Group Number and Name
Member Months (column 2) – Total Member Months for time period selected.
Funding (column 3) – Total Funding amount (premium) for the time period selected.
Capitation Expense (column 4) – Total Capitation Expense for the time period selected.
Claim Expense (column 5) – Total Claim Expense for the time period selected.
Manual Adjustment (column 6) – Total Manual Adjustments for the time period selected.
IBNR Expense (column 7) – Total IBNR Expense for the time period selected.
Total Expense (column 8) – Total Expenses for the time period selected.
Fund Balance (column 9) – Fund Balance for the time period selected.
MLR % (column 10) – Medical Loss Ratio, in percentage format, for the time period selected.
Funding PMPM (column 11) – Funding Per Member Per Month for the time period selected.
Total Expense PMPM (column 12) – Total Expense Per Member Per Month for the time period selected.
Fund Balance PMPM (column 13) – Fund Balance Per Member Per Month for the time period selected.
Provider Group by Fund Type (table)
This table will display details for the first Provider Group selected. This table can be cleared by clicking the Reset button in the header.
Fund (column 1) – Fund line category.
Member Months (column 2) – Total Member Months for time period selected.
Funding (column3) – Total Funding amount (premium) for the time period selected.
Capitation Expense (column 4) – Total Capitation Expense for the time period selected.
Claim Expense (column 5) – Total Claim Expense for the time period selected.
Manual Adjustments (column 6) – Total Manual Adjustments for the time period selected.
IBNR Expense (column 7) – Total IBNR Expense for the time period selected.
Total Expense (column 8) – Total Expenses for the time period selected.
Fund Balance (column 9) – Fund Balance for the time period selected.
MLR % (column 10) – Medical Loss Ratio, in percentage format, for the time period selected.
Funding PMPM (column 11) – Funding Per Member Per Month for the time period selected.
Total Expense (column 12) – Total Expense Per Member Per Month for the time period selected.
Fund Balance (column 13) – Fund Balance Per Member Per Month for the time period selected.
Medical Loss Ratio – Provider Group vs PEERS within Entity (graphs)
This graphs display the Provider Group to Peer comparison for the following categories.
Funding PMPM (graph) – Funding Per Member Per Month comparison of the Provider Group to Peers.
Total Expense PMPM (graph) – Total Expenses Per Member Per Month comparison of the Provider Group to Peers.
Fund Balance PMPM (graph) – Total Fund Balance Per Member Per Month comparison of the Provider Group to Peers.
MLR % (graph) – The Medical Loss Ratio of the Provider Group in comparison to the Peers.
Medical Loss Ratio Trend – Entity vs PEERS (graph)
Compares the selected Provider Group to all other Provider Groups (Peers) within the Entity. The selected Provider Group is represented as a line, and the Peers are represented by bars.
The Y axis is represented by the Medical Loss Ratio % (MLR) and the X axis is represented by the time.
Group Comparison (graph)
This graph allows for the user to compare the initially selected Provider Group to one or more Providers Groups. Press and hold the Control key to select one or more additional Provider Groups. Each group will be represented by a separate line within the graph.
The Y axis is represented by the Medical Loss Ratio % (MLR) and the X axis is represented by the time.