Using prescription drug data for identifying missing diagnoses and for medical management in the Medicare Advantage market

Even though the Centers for Medicare and Medicaid Services does not use prescription data in assigning risk scores, Rx data can still be a valuable resource for Medicare Advantage (MA) plans. Because the revenue for an MA plan each year is based on member diagnoses incurred in the prior year and submitted within 13 months of the end of that period, MA plans have a meaningful period of time to ensure complete and accurate coding as well as to identify members for disease management and potential drug adherence outliers.