Medicare Provider Risk
Assess Your Risk Based on Medicare Utilization by Provider
Data released to the public by the Centers for Medicare and Medicaid Services detail the procedures performed by each physician as well as the amounts they were paid.
Because critical information, such as payer mix, diagnoses codes, patient acuity, etc., were not provided by CMS, using the raw values, such as total services or payments, are basically useless. Our tool has been designed to provide physicians with a real-world perspective on their Medicare billing activity. In order to both understand and benchmark your data, it first needs to be reduced to ratios, which is what we have done here. So, rather than try to compare total payments with that of your peers, it is much more valuable to look at total payments as a ratio of unique beneficiaries — a metric that is agnostic to payer mix and other important data points.
Enter your provider NPI number at the following link and use the interpretation guide on the CRA site or here to gain insight on your level of risk.
For each metric, there are three columns:
- Under Physician are the data associated to the NPI number entered above.
- Under Specialty are the comparative data for the specialty represented by the physician associated to the NPI number.
- The Variance column reports the variance of the physician to the specialty.
- 2012 only contained figures for all services, so only one table is displayed for that year.
- 2013 included figures for medical and drug services, so that year produces three tables.
Each table contains ten rows of data, as follows:
- Unique Procedure Codes – contains the number of unique HCPCS codes reported by that provider, his or her peer group (as an average) and the variance.
- Unique Patients – contains the total number of unique patients reported by that provider and the average for the associated specialty for the selected year.
- Total Services – contains the total number of individual services (or line items and units) reported by that provider and the average number reported by the peer group.
- Total Allowed – reports the total allowed amount assigned by CMS to the total services reported by that provider along with the average total allowed amount for the peer group.
- Total Payments – reports the total amount paid by CMS to that provider along with the average total paid amount for the peer group.
- Paid to Allowed Ratio – contains the ratio of the total paid amount to the total allowed amount. This number should equal or be close to 80% for most specialties.
- Services per Patient – contains the ratio of the total number of services reported per unique beneficiary (patient) along with the specialty comparison
- Services per Patient Percentile – This metric reports the percentile ranking for this provider compared to their peer group for the average number of services provided per unique patient. In our opinion, 75 to 90 (75th percentile to 90th percentile) represents a moderate risk while 90 to 100 (90th percentile to 100th percentile) represents a high risk.
- Payments per Patient – contains the average amount paid to the provider per unique patient and a comparison for the peer group.
- Payments per Patient Percentile – This metric reports the percentile ranking for this provider compared to their peer group for the average paid amount per unique patient. In our opinion, 75 to 90 (75th percentile to 90th percentile) represents a moderate risk while 90 to 100 (90th percentile to 100th percentile) represents a high risk.
What to do next…
- Have questions about regulatory compliance?
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