Medicare Claim Reporting to Milliman

[somarco]

Milliman collects data on drug claims as well as health insurance claims processed by carriers. But AFAIK, Medicare (which is not an insurance company) does not report claims to any outside data warehouses, including Milliman.

Can anyone confirm this or not?

Having trouble with an underwritten Medigap app and Milliman is the fly in the ointment.

 

[Tahoe Ray]

Milliman collects data on drug claims as well as health insurance claims processed by carriers. But AFAIK, Medicare (which is not an insurance company) does not report claims to any outside data warehouses, including Milliman.

Can anyone confirm this or not?

Having trouble with an underwritten Medigap app and Milliman is the fly in the ointment.

I don't know if you've seen a Milliman report lately but they have a crazy amount of information on them. I have one right now on a client that's over 30 pages long in single-spaced, small font.

I routinely have clients order them if they've been previously declined for life/DI and I am frankly shocked with the amount of information that's in there.

It's not just claims. It's scrips and doctor's notes. Literally everything that you can imagine outside of a full APS.

No idea how supps underwrite but if they have the Milliman report, it has a ton of info. Ask the client to order it themselves and get a copy so that you can figure out what's up.

 

[somarco]

I just saw a portion of the Milliman report for my client. The full report was 30+ pages and it had a number of claims that did not match her Medicare claim run.

The carrier denied her application because of a SINGLE test with a diagnosis code for bronchiectasis. Never mind that a doc needs to perform multiple tests to diagnose this illness. The really odd thing is the Milliman report showed 6 tests/procedures on 4/18/2024 and performed at Wellstar Hospital.

Medicare does not show ANY treatment at Wellstar during the month of March.

I haven't seen the full report but my client said they had several other claims, including Chiro treatment, that matched her Medicare report. But there were several other claims listed that did not show anywhere on her Medicare report.

Her data is corrupted and the carriers response is she needs to contact Milliman to get it corrected.

EDIT:
I now have the full report and in short time, have found a number of discrepancies. Enough to make me question the accuracy of anything that comes from Milliman . . .

 

[Tahoe Ray]

I just saw a portion of the Milliman report for my client. The full report was 30+ pages and it had a number of claims that did not match her Medicare claim run.

The carrier denied her application because of a SINGLE test with a diagnosis code for bronchiectasis. Never mind that a doc needs to perform multiple tests to diagnose this illness. The really odd thing is the Milliman report showed 6 tests/procedures on 4/18/2024 and performed at Wellstar Hospital.

Medicare does not show ANY treatment at Wellstar during the month of March.

I haven't seen the full report but my client said they had several other claims, including Chiro treatment, that matched her Medicare report. But there were several other claims listed that did not show anywhere on her Medicare report.

Her data is corrupted and the carriers response is she needs to contact Milliman to get it corrected.

EDIT:
I now have the full report and in short time, have found a number of discrepancies. Enough to make me question the accuracy of anything that comes from Milliman . . .

They certainly make mistakes but those can be corrected.

I have a client that had a surgery listed on his that he never had and they were coding injections he receives for a health condition as treatment for something much more serious.

We were able to get them cleaned up and got his policy issued but it's definitely a PIA.