Paid Amount Greater than Total Amount Paid - sql

Question

I have an Access DB I am maintaining for a client.
I have 4 tables. Claims, Eligibility, Pharmacy, and Codes.
The Primary Key I am using is PHID + SID = MemberID which I am linking to each table, and then the Codes table is merely used for a description. See queries below for better visualization of that...
Query 1: Member_Claims_Query
SELECT
Eligibility.GROUPID,
Eligibility.PHID & '-' & Eligibility.SID AS MemberID,
[Eligibility].[DOB] AS DOB,
Eligibility.GENDER,
Eligibility.RELATIONSHIP_CODE,
MaxDiagDollars.HighestDiagPaid/SUM(Claims.PAID_AMT) AS ['%'],
MaxDiagDollars.HighestDiagPaid/SUM(Claims.PAID_AMT) as 'Percent',
ROUND(SUM(Claims.PAID_AMT)) AS TOTALPAID,
ROUND(Sum(IIf(Format(Serv_Beg_Date,'yyyy')='2011',Claims.PAID_AMT,0))) AS 2011TOTALPAID,
ROUND(Sum(IIf(Format(Serv_Beg_Date,'yyyy')='2012',Claims.PAID_AMT,0))) AS 2012TOTALPAID,
ROUND(Sum(IIf(Format(Serv_Beg_Date,'yyyy')='2013',Claims.PAID_AMT,0))) AS 2013TOTALPAID
FROM (Claims
INNER JOIN Eligibility
ON (Claims.[SID] = Eligibility.[SID]) AND (Claims.[PHID] = Eligibility.[PHID]))
INNER JOIN (SELECT PHID, SID, MAX(TotalPaid) AS HighestDiagPaid
FROM (SELECT [PHID], [SID], DIAG_CODE1, SUM(PAID_AMT) AS TotalPaid FROM Claims GROUP BY [PHID], [SID], [DIAG_CODE1]) AS [%$###_Alias] GROUP BY PHID, SID) AS MaxDiagDollars ON ( MaxDiagDollars.[PHID]=Eligibility.[PHID] ) AND ( MaxDiagDollars.[SID] = Eligibility.[SID] )
WHERE Eligibility.DOB < DateAdd( 'y', -2, DATE())
GROUP BY
Eligibility.GROUPID, Eligibility.PHID & '-' & Eligibility.SID, [Eligibility].[DOB], Eligibility.GENDER, Eligibility.RELATIONSHIP_CODE, MaxDiagDollars.HighestDiagPaid
HAVING SUM(Claims.PAID_AMT)>10000 and MaxDiagDollars.HighestDiagPaid/SUM(Claims.PAID_AMT) <= 0.80;
This query is supposed to take the Total Amount Paid per Member and give a Total Amount PAid, and then yearly break outs.
Query 2: Member_By_Diag
SELECT
Eligibility.PHID & '-' & Eligibility.SID AS MemberID,
Claims.Diag_Code1,
ROUND(Sum(Claims.PAID_AMT)) AS TotalPaid,
ROUND(Sum(IIf(Format(Serv_Beg_Date,'yyyy')='2011',Claims.PAID_AMT,0))) AS 2011TotalPaid,
ROUND(Sum(IIf(Format(Serv_Beg_Date,'yyyy')='2012',Claims.PAID_AMT,0))) AS 2012TotalPaid,
ROUND( Sum(IIf(Format(Serv_Beg_Date,'yyyy')='2013',Claims.PAID_AMT,0))) AS 2013TotalPaid
FROM
(Claims
INNER JOIN Eligibility
ON (Claims.[SID] = Eligibility.[SID]) AND (Claims.[PHID] = Eligibility.[PHID]))
INNER JOIN Pharmacy
ON (Eligibility.SID = Pharmacy.SID) AND (Eligibility.PHID = Pharmacy.PHID)
GROUP BY
Eligibility.PHID & '-' & Eligibility.SID, Claims.Diag_Code1
HAVING count( [Pharmacy].[NDC] ) >4 and count(IIF(Claims.REV_CODE= '450',1,0) ) > 1
ORDER BY Eligibility.PHID & '-' & Eligibility.SID;
The second query is essentially supposed to take the Codes for each member and break out their amount paids by Diagnosis code.
Query 3: combined_query
SELECT *
FROM (Member_Claims_Query AS a INNER JOIN Member_by_Diag AS b ON a.MemberID=b.MemberID) INNER JOIN Codes AS c ON c.DxCode = b.Diag_Code1;
ISSUE
My Client sent me an e-mail stating that the Total Paid in the Member_By_Diag query is sometimes higher than the Total Paid by the Member_By_Claim query. yet they are being computed the same way.
I opened up the DB and wrote a simple query to see how many records were returning where the b.Total_Paid ( Member_By_Diag.Total_Paid) is greater than the Member_Claims_Query.Total_Paid.
It returned 262/1278 records where this was the case.
SELECT * FROM Combined_Query WHERE b_TotalPaid > a_TotalPaid
This picture acurately describes what I am seeing along with my client.
As you can see. a_TotalPaid > b_TotalPaid. But if you look up at my query, they are the same? Is this a group by issue? or a join issue? Any help would be much appreciated.

Answer 1

There are a couple of differences between the queries that could be contributing to this. The main culprits are your INNER JOIN statements and your HAVING statement. Those could easily be excluding records that will have an effect on your TotalPaid field. Without the original dataset, there's not much I can tell you, but you may want to run those queries and play with removing and inserting the various INNER JOIN and HAVING clauses to see which one is deleting the records that are causing your totals to not be equal.

Answer 2

I appreciate the answers everyone... You didn't exactly answer the question, but the inner join on Pharmacy was causing the issue, I was specifically using it in relation to the HAVING clause, when I added a count(*) I noticed it was actually multiplying my results. For Ex. If a member had 7 claims, and 6 Pharmacy records it was multiplying it making it 42 records making my total paids extremely high, and they weren't relating to the CLAIMS themselves...hence the ultimate issue. Here is the solution in the Member_By_Diag Query:
SELECT Eligibility.PHID & '-' & Eligibility.SID AS MemberID, Claims.Diag_Code1, Round(Sum(Claims.PAID_AMT)) AS TotalPaid, Round(Sum(IIf(Format(Serv_Beg_Date,'yyyy')='2011',Claims.PAID_AMT,0))) AS 2011TotalPaid, Round(Sum(IIf(Format(Serv_Beg_Date,'yyyy')='2012',Claims.PAID_AMT,0))) AS 2012TotalPaid, Round(Sum(IIf(Format(Serv_Beg_Date,'yyyy')='2013',Claims.PAID_AMT,0))) AS 2013TotalPaid, Count(*) AS Expr1
FROM (Claims INNER JOIN Eligibility ON (Claims.[SID] = Eligibility.[SID]) AND (Claims.[PHID] = Eligibility.[PHID])) INNER JOIN ***(SELECT PHID, SID, COUNT(NDC) AS RXCount FROM Pharmacy GROUP BY PHID, SID ORDER BY PHID, SID) AS Pharmacy*** ON (Eligibility.SID = Pharmacy.SID) AND (Eligibility.PHID = Pharmacy.PHID)
GROUP BY Eligibility.PHID & '-' & Eligibility.SID, Claims.Diag_Code1
***HAVING Count(IIf([Claims].[REV_CODE]='450',1,0))>1***
ORDER BY Eligibility.PHID & '-' & Eligibility.SID;
This made the dollars look much more reasonable. Thanks everyone.