Dates and Dollars: Pillars of Understanding Your Data
Ralph Hooper, Director of Client Services, San Rafael, CA
Key to understanding and using the data in any RMIS is understanding the substance and nuances in the date and dollar fields that populate and clarify the claim panels and reports. Over many years of working with clients on data issues and reporting questions in a RMIS environment, I can say that 95% of the questions or ambiguities have revolved around data, the interpretation of data and how to use it. In this article I will review critical date and financial fields, what they mean and how they are used.
Reporting Dates
When is a claim officially reported? How often are we asked to provide reporting period data? Sigma EncoreSM provides three standard reporting fields: Client Notified Date, Carrier/TPA Notified Date, and Insurance Company Notified Date, as well as an alias Report Date field that can be set to any one of the three.
The Report Date alias appears in many of RSG’s standard SESM Report templates and is a requirement on many state and other custom reports. Each client can determine how to assign the Report Date field in its system.
An accompanying critical measurement is the lag between a claim occurrence and the date of its reporting. Sigma EncoreSM matches each of the three reporting dates with three standard lag fields: Client Lag Days, Carrier Lag Days, and Insurance Company Lag Days. These fields are available for querying claims in Sigma EncoreSM and SESM Reports through the Advanced Search data tree. They are also available in the 03-DATE category in the Claims Current Evaluation and Point-in-Time Evaluation business areas in Oracle® Discoverer.
Reopen and Close Dates
Many claims close, reopen and close again a number of times. It is often important to track when these claims first closed and first reopened. Sigma EncoreSM provides first close and first reopen date fields. The standard close and reopen date fields display the last or latest close and reopen.
Activity Date and Evaluation Date
Perhaps the most critical of dates is the Evaluation Date. Any point-in-time reporting is tied to this field. Often, Evaluation Date and another important temporal yardstick, Activity Date, are confused. These fields have different objectives.
Activity Date tracks the most recent data change in a claim record. Perhaps a financial amount is entered or the claim is closed or reopened. Adding an adjuster note is the only claim activity that does not trigger an update to the Activity Date, which is system generated. Activity is about change, specifically when change occurred.
Evaluation is a snapshot in time, like a balance sheet. What were the values in fields having an audit trail on a given date? The key audit trail fields in Sigma EncoreSM are the financials and claim status.
How does Sigma EncoreSM remember what values are tied to what evaluation dates? For Carrier/TPA data that RSG loads at regular intervals, the claim and financial data in the audit fields is tied to the date of the update file. For a monthly cumulative file from Carrier X that is a snapshot of that data as of 2/28/2009, the evaluation date of the claims in the file is 2/28/2009. Some may have had activity (additions/changes) in February, many may not. In early April, RSG will load a new update file, and that snapshot in time will be as of 3/31/2009. Many audit fields will not change in the new snapshot, some will.
But how do we assign an Evaluation Date to in-house claims where our clients enter all the data? The answer is that our clients assign evaluation dates. When a claim analyst clicks the <Edit> button and changes the claim status code to ‘C’, the analyst also updates the Evaluation Date field that is displaying the date of the last evaluation update. Unlike the Activity Date field, which is system controlled, the Evaluation Date field for in-house claims is controlled by our client users. The analyst may enter today’s date or another “eval” date; the Activity Date is always the current date.
Financials and Clarity
We work with these financial fields every day in countless queries and reports. And yet we are often not clear about what we really want. Recently I have been working on a very large state report project involving multiple clients, most of the states, and every conceivable financial requirement. Ambiguity thrives in many state requirement documents. They ask for one thing but really want something else. “Reserves” can mean Reserves in one case and Outstanding Reserves in another. “Reporting Period” can mean a period measured by Report Date or, in another case, a period measured by Accident Date. Then there is the case of the two identical reports, each mingling claim financials and payment data by accident year, but each measuring total outstanding differently: in the one case, asking for complete total outstanding by accident year, in the other only wanting total outstanding by accident year for claims that had payments in the most recent “reporting year”! Clarity of purpose is always the key to success.
Financial Data Items and Calculations
In Sigma EncoreSM, Reserves and Paid amounts are actual data items; Incurred and Outstanding amounts are calculated. Reserves and Paid amounts are uploaded for carrier claims and entered by clients for in-house. For open claims, Incurred is set to the Reserve amount. When the claim is closed, the system automatically resets Incurred to equal Paid. Since Outstanding equals Incurred minus Paid, the Outstanding for closed claims is zero.
Gross/Loss/Net Totals
Sigma EncoreSM offers three methods of totaling financial buckets:
While our default setting is Net, Gross and Loss are often the reporting requirement.
Expense Types
Total Expense is broken into three types: Admin Expense, Legal Expense and Other Expense. Like all entered data, the accuracy of these fields depends on the quality of input. For carrier/TPA data, check with your account manager on the accuracy and consistency of these items. Carrier/TPAs that send payment data offer another gage of expense type through the specific pay code attached to each payment.
Recovery and Refund
Recoveries traditionally consist of salvage and subrogation. Some of our clients make a clear distinction between recovery and refund, and these are treated quite differently. Recoveries are a separate bucket and are often excluded from reporting, including in many state reports. Refunds (or reimbursements) are reductions of Medical, Indemnity, or Expense payments and are usually counted in reporting.
Net and Cumulative Change Grids
Sigma EncoreSM provides nice financial summary tracking by month in net change and cumulative change grids. A drop-down list provides nine views that track financial development by buckets as well as by Reserve, Incurred, Paid, and Outstanding.
 
While the system defaults to monthly tracking, RSG can customize to different time intervals. For example, one of our clients with daily claim updates requested that we provide Reserve tracking on a daily basis while the other eight grids remain monthly. On the Reserve grid we have added a reserve change code column to identify the reason for the reserve changes. These underutilized grids offer many creative possibilities.
Financial Reporting
In SESM Reports, the Detailed Financial Summary standard report offers an excellent delineation by accident year and by bucket of Incurred, Paid, and Outstanding financials as well as claim counts and status as of the evaluation date you choose.
An even larger palette of cumulative financial fields is available in Oracle® Discoverer, in the 04-FIN category in the Claims Current Evaluation and Claims Point-in-Time business areas. Here you get expense and recovery type breakouts as well as gross, loss, and net totals.
If you have not investigated all of the financial templates in Sigma EncoreSM Reports or the wonders of Oracle® Discoverer, contact your account manager. In working with financial fields in queries and reports, clarity of understanding as to your exact requirements will make for a rewarding experience.
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