White Paper

Accuracy of Claims-Based Risk Scoring Models

Published by Society of Actuaries (SOA)
by Geof Hileman, FSA, MAAA, Spenser Steele

The Society of Actuaries is pleased to make available research material that presents the results of a study comparing health risk scoring models. The study builds on prior SOA studies with a similar objective. The study uses 3M Clinical Risk Groups (CRGs), v2.0. CRGs are a classification system for describing the health status and burden of illness of individuals in an identified population. CRG relates the historical clinical and demographic characteristics of the enrollee (claim based diagnosis, procedure, pharmaceutical, and functional health status) to the amount and type of healthcare resource that enrollee will consume in the future. In addition, CRGs can be linked to critical outcomes such as rates of potentially Preventable Readmissions and Emergency Department Visits. For this study, a pre-release working version of the V2.0 CRG software from August 2015 was used. The fully updated V2.0 CRG software released by 3M in May 2016 contained additional updates to its categories and logic, but was not available in time to be used for this study.

Publication Date: 2016

View White Paper (PDF)