What is Estimated Spend in my Pearl Platform?
This is an estimate by Pearl of how your patient panel's cumulative spend (includes both Part A and Part B) compares to the benchmark, which is the budget Medicare allocated for your organization. This ratio is commonly known as the Medical Loss Ratio (MLR).
The estimate may be informative as directional guidance for how you're doing in a given performance year, but final results may vary.
How should I interpret my MLR?
A lower MLR is a better MLR. An MLR estimate below 100 indicates that your patients' total medical expenditure seems to be tracking to less than the CMS benchmark. This indicates a well managed population, and can help drive shared savings for your organization.
What affects the benchmark Medicare allocates to my practice?
CMS sets your current year benchmark based on a mix of factors, including your patients' conditions as diagnosed in the prior year, regional cost of care utilization, and proportion of underserved Medicare beneficiaries in a given population. If CMS has an inaccurate understanding of your patients' overall health because their current conditions were not accurately coded in prior year(s), your annual benchmark may not reflect all the care that your patients will need.
While patient conditions documented this year will not influence your current year's benchmark, we recommend continuing to document conditions accurately and diligently to ensure a properly calibrated benchmark for next year.
You can learn more about how billing and coding affect your overall benchmark by logging into Pearl Community and navigating the Pearl Academy Billing & Coding training module.
Why is there variability in my MLR estimates?
While we use the latest available claims data from CMS to calculate these estimates, the data we receive can be incomplete due to time required by CMS to process and adjudicate claims. Because of these processes, variability tends to be higher in recent months than preceding months.
How recent is the data being used to calculate my MLR?
The claims used to calculate your MLR will typically not include data from the most recent 2 to 3 months. Claims often take more than a month to fully process, which means the data we receive from CMS is usually incomplete for more recent months.
Notifications: The content of this document, the resources described herein and any related discussions (“Materials”) are for informational purposes only and not intended to provide guidance on medical, compliance, billing or other matters. All diagnosis and treatment assessments and determinations are to be made by duly licensed practitioners exercising independent judgment. You are responsible for making sure all your billing and coding is accurate, complete and consistent with applicable statutes, rules and regulations.