The Episodes of Care are defined as one or more surgical procedure codes that begins the episode and accumulates costs to the member for the following 90 days.  This report tracks costs associated with medical/surgical episodes by provider and patient.

 

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

Episodes accumulate all medical costs (IP, OP, and Professional) for 90 days after the event that triggers the episode.  Medical Management can track overall average episode cost, as well as, IP, OP and Professional costs, and average cost per episode.  Further details include a breakdown by episode providers and patients.  This can be used to determine providers for higher/lower cost of care by episode.

Detail and Definitions

Episode list can be found in Appendix A

 

Episodes

  • Episode
  • Total #
  • Average $
  • Complication Rate

 

Episodes by Provider

  • Provider NPI
  • Provider Name
  • Total #
  • Total $
  • Average $
  • Efficiency Ratio – Provider Average Cost per Episode / Average Cost per Episode.  Efficiency Ratio less than one is lower than average cost.  Efficiency Ratio greater than one is higher than average cost. 
  • Risk
  • Complication
  • IP $
  • OP $
  • Professional $

 

Episodes by Member

  • Member Number
  • Date
  • Member Name
  • Total $
  • IP $
  • OP $
  • Professional $
  • ALOS
  • Risk
  • Episode Name

 

Episodes by Provider

  • Provider Efficiency Ratio
  • Member Risk Score