ER SuperUser is the shorthand term for frequent emergency room users and the characteristics of these members are described in this report.   The ER is often an inappropriate site for care and obtaining care in the ER on a regular basis leads to fragmented health and disease management for members.  Avoidable ER visits can result in avoidable hospitalizations and the outcome is an expensive method of delivering health care that could be provided in a less urgent setting.

 

 

 

Target Audience for this Report

Chief Medical Officer, Compliance & Regulatory Department, Finance Department and CFO, Leadership Team, Medical management/Care Management Department, Physician Relations, Quality Management, and Utilization Management.

 

Business Processes Impacted by this Report

Member and family education provided to ER SuperUsers to increase their understanding of alternatives to the ER and the importance of establishing care with a PCP.


 Network evaluation of PCP’s identified with a high number of ER SuperUsers to determine their ability to provide access to members when illness or injury occur.


Medical Management will track and trend ER SuperUsers to determine specific outreach to members and PCPs.  For example; “Are ER SuperUsers seeking care with a PCP?”, “Does the ER visit follow an inpatient admission?”, “Are the diagnoses of the ER visit consistent and indicate a need for Disease Management?”.

Detail and Definitions

 

Filters

  • Claim Type (All, Professional, Facility) – Determines how the ER visits are counted.  All is the default and should be used for most clients, unless client does not have Facility claims.
  • Count Members with: - This effectively sets the threshold for what the user determines to be a “SuperUser”.  For instance, if the count is set to “3” any member with three or more ER visits in the detailed reporting period will be flagged as a SuperUser.  Since the report threshold is driven by member ER visits (and not total PCP ER visits), it is possible for a member to be attributed to more than one PCP and to still be regarded as a SuperUser.
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Header

  • ER Visits – Number of visits that count as at or above the defined count per member.
  • Visits – Total ER visits with percentage that are considered superuser visits.

 

ER Superusers by PCP

  • PCP ID
  • PCP Name
  • Super Users
  • ER Visits
  • Total Paid
  • Cost/Visit
  • Average Risk Score
  • Avoidable ER %

 

ER Superusers

  • Member Name
  • Member Number
  • ER Visits
  • Avoid ER %
  • Total Paid
  • Cost/Visit
  • Risk Score
  • Savings Opp
  • % of Savings

 

ER Superusers by Risk

  • Number of ER Superusers
  • Member Risk Score

 

Member ER Visits

  • Service Date
  • Claim #
  • Member Number
  • Member Name
  • POS
  • Provider
  • Diagnosis 
  • Avoid ER