How to outsmart your

competitors with claims

data and analytics

LexisNexis® MarketView™

MAY 16, 2019

Anja Maciagiewicz, Vertical Solutions ConsultantEmily Mortimer, Director Product Implementation and Analytics

Agenda

• About LexisNexis Risk Solutions

• MarketView solutions: What we offer, how it helps build market share

• Claims Adjudication

• Provider Reimbursement Insights

Overview

Example use cases

Data insights

• Q&A

LexisNexis MarketView 2

3LexisNexis MarketView

Use claims-based intelligence from MarketView Provider Reimbursement Insights to arm pricing and contracting teams with actionable insight to:

• Understand reimbursement rates across payers and respond to a competitive landscape

• Develop more informed pricing models and strategies

• Allocate resources more efficiently and effectively to drive higher contract values

MarketView Provider Reimbursement Insights

Overview of LexisNexis® Risk Solutions

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All top 10 pharmacy retailers

>3K provider organizations

Customers in more than 100 countries

8 of top 10 life science companies

90% of US commercial payers

80% of U.S. Federal Agencies

70% of Local Governments

LexisNexis® Risk Solutions is a global company with significant presence

LexisNexis MarketView

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...

534million

criminal records

19.3billion

consumerrecords

1.5billion

bankruptcyrecords

monitored

282million unique

cell phones

1.2billion vehicle

title records

50million active

U.S. business entities (LexIDs)

10.3billion unique name/

address combinations

5billion

property records

5.6billionmotor vehicle

registrations

23.5billion

insurancerecords

Partial snapshot of our U.S. data sets as of 8/1/17

Vast Data AssetsOver 6 Petabytes of Unique Data, 65+

Billion Public Records

LexisNexis collects data from over 10,000 consumer and public record sources that identify personal and professional entities

LexisNexis MarketView

Top 10 Retail

Pharmacies

Major Health

Systems

National Payers and

Health Plans

Top 20 Life Sciences

Organizations

Federal and State Agencies

Quality data and advanced analytics to fuel the future of healthcare

7LexisNexis MarketView

MarketView™

MarketView for Healthcare links to many LN vast datasets based on targeting and use case requirements

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The data

LexisNexis MarketView

HEALTHCARE PROVIDERS

• 1M+ unique practitioners

• Rollup to IDNs

• 900+ payers

• 400K accounts

DATA SOURCES

• Government agencies

• Clearinghouses and switches

CAPTURE AND COVERAGE

• 1.4B+ annual medical claims

• 165M unique patients

• No geographic bias

• Inpatient, outpatient, office, ASC, lab, home, post acute care

UPDATES

• As frequently as daily

Medical Claims and Reimbursement

Claims adjudication cycle overview

1 – Medical Visit

2 – Coding Entered

3 – Verification and Claim

Submission

4 –Denial/Change

Process

5 – Insurance Validation

6 – Payment Issued

LexisNexis MarketView 12

Claim remittance 835 form

Claim submission837 form

Potential change and resubmission of 837

MarketView medical claims data 101: Anatomy of a submitted claim

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Diagnosis: ICD-10-CM code for appropriate diagnosis or nature of illness

Procedure: CPT code for services provided to an established patient

Drug: Appropriate HCPCS code for medication administered

Patient Information: Age, gender, location

Payer: Government/commercial insurance company responsible for payment

Practitioner(s): HCP(s) responsible for care of patient

Facility: Location where service was provided

LexisNexis MarketView

MarketView medical claims data 101: Remittance advice

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Procedure: CPT code for services provided to an established patient

Procedure details: key details like procedure modifier codes, units, etc.

Allowed Amount: Appropriate HCPCS code for medication administered

Payer: Government/commercial insurance company responsible for payment

Payee: HCP(s) receiving payment for claim submission

Place of Service: Type of location where service was provided

MarketView™ Provider Reimbursement Insights

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31,171 PROCEDURES AND INFUSED DRUGS

MarketView Provider Reimbursement Insights

2,590 PAYERS 586,750 PAYEES

Summary level reports based on actual remitted medical claims data from sources that update daily

Average allowed amount metrics by:

• CPT Code/Payer/Payee (HCP/HCO)

• Min/Max/Mean/Median/Mode

• Rollup to national or geography

• Modifier and Place of Service

• Updated quarterly

94M UNIQUE PATIENTS551M UNIQUE CLAIMS

Copyright © 2018 LexisNexis. All rights reserved. Cannot be copied in part or whole without written consent from LexisNexis.

• ROI• Helps facilities understand when they will see a return on their investment for office equipment.

• Competitor Pricing• Aid companies with their pricing models to stay competitive in the market.

• Allow companies to monitor and respond to market changes.

• Drives utilization by helping providers maximize reimbursement.

• Contract Negotiations• Viewing average reimbursement rates for different payers and facilities, companies can develop

more informed pricing and contracting models/strategies.

PRI use cases

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United HealthGroup Aetna HumanaName

Place of Service Home/DME Home/DME Home/DME

Modifier RR RR RR

Average Payment $75.05 $77.32 $70.54

Median Payment $70.23 $77.16 $76.24

Minimum Payment $7.37 $65.70 $13.14

Maximum Payment $260.00 $121.46 $121.46

Number of Payments 12,066 1,624 4,110

Average Units 1.0 1.0 1.0

E1390 - Oxygen concentrator, single delivery port, capable of delivering 85 percent or greater

oxygen concentration at the prescribed flow rate

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Average Payment $75.05 $77.32 $70.54

Median Payment $70.23 $77.16 $76.24

Minimum Payment $7.37 $65.70 $13.14

Maximum Payment $260.00 $121.46 $121.46

LexisNexis MarketView

MarketView Provider Reimbursement Insights: Identify payment variations by payer for the same provider and services

MarketView Provider Reimbursement Insights: Identify potential regional trends in reimbursement

19LexisNexis MarketView

California Allowed Amounts by Payer for E1390

In this scenario, the state of CA shows little variability in median payment, however:

• Certain payers are more flexible with outliers, including Unitedhealthand BCBS

• This is especially true of lower values for BCBS and higher values for UHC

MarketView Provider Reimbursement Insights: Identify variations in payment for the same provider by place of service

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Within a single payer, median payment amounts may vary by setting of care and product. In this market:

• Office-based care is reimbursed at a higher rate -

• Allowed amount per unit is more than double that in the home setting

• At the product-level, some are very stable across setting, some have wide swings

$8.23

$40.09

$7.69

$35.48

$21.78

$38.21

$17.52

$13.36$15.40

HOME OFFICE OTHER

All

ow

ed A

mo

un

t pe

r Un

it

Reimbursement Variation by Place of Service

J1561 J1566 J1568 J1569

$45.24

$38.01

$46.69 $45.51

$38.41

$32.94 $36.09

$40.19

$58.47

$50.41

$37.20

$46.38

J1561 J1566 J1568 J1569

Price Variation Among Products by Payer

Unitedhealth Group Medicare BCBS

MarketView Provider Reimbursement Insights: Identify variability in pricing and reimbursement among competitive products

21LexisNexis MarketView

• Across similar products, negotiated payment rates may differ:

• In a set of similar products with overlapping indications:

• Different rates across payers, but also different positions

• Different products are the highest and lowest amounts for different payers

• Some payers vary greatly by product, others show less variability

• Data and Analytics are necessary to drive key strategic decisions

• Medical claims data supports targeting efforts, understanding of patient flow, market trends and more

• Remittance data provides an edge over the competition and can inform many areas of your businss

Summary

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Any Questions?

LexisNexis MarketView

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About LexisNexis® Risk SolutionsAt LexisNexis Risk Solutions, we believe in the power of data and advanced analytics for better risk management. With over 40 years of expertise, we are the trusted data analytics provider for organizations seeking actionable insights to manage risks and improve results while upholding the highest standards for security and privacy. Headquartered in metro Atlanta USA, LexisNexis Risk Solutions serves customers in more than 100 countries and is part of RELX Group plc, a global provider of information and analytics for professional and business customers across industries. For more information, please visit www.risk.lexisnexis.com.

Our healthcare solutions combine proprietary analytics, science and technology with the industry’s leading sources of provider, member, claims and public records information to improve cost savings, health outcomes, data quality, compliance and exposure to fraud, waste and abuse.

LexisNexis and the Knowledge Burst logo are registered trademarks of RELX Inc. Copyright © 2018 LexisNexis. All rights reserved.