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Review Claims Data

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Reviewing claims data will provide data that you can compare to the employee health survey/health risk assessment.  This comparison will give you a stronger basis for wellness program development and making the business case to senior management.  Reviewing claims data periodically will also help you evaluate the effectiveness of your wellness efforts.

Pharmacy Data

Your company’s pharmacy vendor can provide information on medications that employees are purchasing. Information will be provided in a report that does not list specific patients/employees but will list medication types, what they are used for and the number of employees who take this medication. This information can be used in planning Diabetes at Work programming.

For example, if employees are filling their prescriptions regularly, they might have fewer complications. Fewer complications can mean greater health care savings over the long term. In the short term, however, there may be an increase in pharmacy costs. But savings from fewer emergency room visits and hospital stays generally offset this increased cost.

Medical Data

Your company’s medical vendor can provide aggregate information on employees’ medical services, diagnoses, and treatment. Understanding this data before the start of a worksite wellness initiative will help you design programming. Measuring claims data periodically will help you determine the initiative’s effectiveness.

In reviewing claims data, look for visits to general medical providers or specialists, such as endocrinologists for diabetes consultations. Look for consultations with diabetes educators and/or Certified Diabetes Educators, vision specialists, podiatrists, and dentists, as well as laboratory tests. Important claims data also might be related to diagnosed diabetes, prediabetes, gestational diabetes, obesity, high blood pressure, heart disease, or kidney disease.

Aids & Tools

Know More

    1. The CDC offers the Healthier Worksite Initiative to help businesses plan and implement worksite wellness.
    2. Learn more about worksite wellness and safety from the American College of Occupational and Environmental Medicine.
    3. The Centers for Disease Control also has resources within the Total Worker Health Initiative.
    4. The National Healthy Worksite Program [PDF – 237 KB] from CDC also provides additional resources.

Ask More

  1. Can’t we just host a screening event to find the people with diabetes and prediabetes?
    Answer:
    Screening for diabetes is best done in a physicians office according to diabetes screening guidelines published by the American Diabetes Association. Random public screenings are not recommended due to the risk of disease transmission and inaccurate results.  For more information see the article in Diabetes Care.
  2. How often should medical data be reviewed?
    Answer:
    Annual review of health data will help wellness professionals identify trends in both employee needs and in the effectiveness of wellness efforts.
  3. Should medical data be compared to previous reviews?
    Answer:
    Yes, but be cautious.  There are a variety of factors that can affect the data such as changing demographics within the work force and overall community health and wellness factors.  For example, if a large number of employees retire and are replaced with a predominantly younger workforce this change will impact the health data for your company apart from any wellness efforts the company is engaged in.
  4. Are there any HIPAA regulations related to medical claims reviews?
    Answer:
    Learn more about HIPAA and its applications here.

Do More

  1. Conduct a medical claims review.  Information on claims review is found here.
  2. Consult a local occupational medicine expert to help you determine trends and unusual health care usage.

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