USING CLAIMS DATA TO MONITOR HOSPITAL UTILIZATION

Controlling provider use is a continuing problem for health care insur ers. This paper describes a Blue Cross and Blue Shield of Michigan sys tem that places primary responsibility for inpatient admissions on par ticipating hospitals and uses a dual monitoring approach. Expensive an nual samples that review medical records against published criteria co nstitute the basic test of compliance. An inexpensive indicator is dev eloped;quarterly using automated universal claims review. Statistical methodology, costs, and savings for both monitors are described. The c laims monitor uses diagnosis related group (DRG) characteristics to es timate the percentage of inappropriate utilization from historical val ues for the patient group.