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Loading claims related data to CDM


(Abhishek kumar verma) #1

We are planning to load the claims data to the CDM , we dont find any table related to claims where we can load the claims data like claimid,claim type , claim amount and the policy details like policy id , policy description etc in the CDM database .We are thinking of putting the claim amount in the cost and the claim related details in separate table , is that fine . Any thoughts where can we load these columns in CDM database?


(Ben Holmes) #2

The Cost table is a long version where you can out concepts of copay, coinsurance, deductible etc. The visit table can handle some of the claim data. There’s also a diagnosis and procedure table to link to visits. It is not structured like we normally handle our claims data but it fits better for analytical function, in my opinion.


(Qi Yang) #3

@abhiiitr02
Why do you need fields like claim id, claim type, policy Id and policy description?


(Abhishek kumar verma) #4

Thanks , we need to store the claim settled date , claim approved amount ,room details , denial clause , approval remarks etc . Is it possible to store it in CDM by adding the column to the existing table ? We need this to run our use case .


(Christian Reich) #5

@abhiiitr02:

The OMOP CDM is for analyzing patient data. It’s not a claims management system. If you have a claims database, why would you want to OMOP it? If you intend to do observational research you need none of those details you mentioned. If you want to run an insurance you don’t need the OMOP CDM. So, feel free to add any tables and fields you want, but the standard methods and tools will not see them. In other words, you are outside the standard if you do that.


(William Johns) #6

We would like to offer our viewpoint that integrating complete and detailed claims data to the OMOP CDM along with the patient data would offer tremendous value. It seems that every element of the healthcare industry at a macro and micro level is looking to find the connection between effective care and acceptable cost. Unfortunately, a good understanding of how care and cost are related is elusive. In a scenario where observational analysis of clinical data reveals no differentiation of outcome from two alternative therapies, the story does not need to end there if we find that one therapy is much more costly than its alternative. Another scenario might find in the clinical data an innovative and effective therapeutic approach that generates high level of claim denials. Both of these findings have medical, commercial and public policy value.

We are new to OHDSI, but are very impressed with what we have found so far. Our current intention is to use the CDM as a base layer in our dataset and supplement it with our detailed financial tables. If there are other participants who are on this journey, we would be open to comparing notes.


(Christian Reich) #7

@Bill_Johns:

Hm. Not sure I understand. OMOP has a cost table, which can be used to calculate cost of therapy outcomes. And folks are doing that kind of work, but currently not a lot. Would be wonderful if you could contribute use cases and questions that the community could engage answeriin ng.

Claim denials are indeed not possible to study right now. And actually, I would find it tremendously valuable if we could take it further and discuss a model of claiming rules. What is allowed to claim, under what circumstances, in what combinations, with what timing. There is a huge gap here. It would help to determine what code is available with what performance characteristics (sensitivity, specificity), which right now we have no systematic way of knowing. However, unfortunately this information is completely obscure. It does exist, but not in one place, machine-readable, for all aspects of medical care. Medical coders in the hospitals know it from special consultancy groups and a myriad of PDF publications the CMS or payers put out. But again, we have no systematic access. Any good idea how to tackle that?


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