Medicare claims intelligence for drug commercialization
For every therapeutic area you work in, we have developed deep TA expertise built on 14 years of granular Medicare claims analysis. We answer the questions your commercial strategy depends on.
Five Stages. One data foundation
CareSet is a healthcare analytics company and an expert in Medicare analysis. We transform 100% of Original Medicare, Parts A, B and D claims into pharmaceutical intelligence. With 25+ years of longitudinal data behind every analysis, pharmaceutical teams have applied our work across more than 200 brands, at every stage of the drug lifecycle from medical affairs through market access, commercial operations, and regulatory decisions. Because we deliver monthly Medicare claims as a census rather than a sample, no brands, accounts, or payors are blocked from view.
FFS Claims
Pre-Clinical Strategy
Treatment Journey
Longitudinal sequencing of how Medicare patients move through lines of therapy: what physicians prescribe, in what order, how long patients stay on treatment, and where they discontinue or switch. Covers the full Medicare FFS population, not a sample.
Diagnostic Journey
The path from initial presentation through testing, referral, and treatment initiation: how long each step takes, where patients fall out before reaching treatment, and how that varies by geography and care setting.
MarketView
Total patient volumes, market share, and competitive dynamics across 100% of Medicare FFS claims, by indication, geography, care setting, and brand. No projections. No sample correction.
Disease Benchmark Impact
Benchmarks disease burden and treatment performance across the Medicare population to frame where an indication's opportunity is strongest.
Clinical Trial Recruitment
KOL Targeting
Investigator identification using Medicare claims: who is treating the relevant patient population, at what volume, and within what proximity to potential trial sites. Built from what physicians actually do, not what they self-report.
Health Equity
Race, ethnicity, and income segmentation across Medicare beneficiaries. Supports clinical-trial diversity recruitment and diversity reporting under FDA guidance, identifying patient populations that traditional site selection misses.
Patient Proximity Networks
Map the geographic and referral relationships between trial sites and patient populations.
Market Access
Treatment Journey
Patient flow across therapy lines and payer settings: where patients start, switch, and discontinue. Used here to understand payer-driven treatment patterns before launch, with full visibility across all PDP and MA-PD plans. No brand blocking; includes restricted accounts.
MarketView by Pharmacy Type
Market share and patient volumes segmented by pharmacy type: retail, specialty, mail order, with visibility into PBM contracting and payment dynamics. Built from 100% of Medicare Part D claims.
Part D Payer and Plan-Level Data
Regional plan utilization by plan, provider, and geography, including blocked and restricted accounts that commercial sources cannot reach. No brand blocking means competitor dynamics are fully visible across every plan.
HEOR
Evidence generation using Medicare claims data to support formulary submissions, payer negotiations, and peer-reviewed publications. The methodology is held to the same standard that governs academic publication, validated through independent peer review.
Commercial Operations
HCP Trigger Alerts
Monthly alerts when a physician crosses a defined clinical threshold in the Medicare record: new diagnoses, therapy switches, competitor adoption. Every alert reflects observed prescribing behavior, not a projected estimate. Medicare signals arrive months before comparable commercial data.
NPI Dept-Level Targeting
Prescriber identification and segmentation at the NPI level, with department and service-line reclassification beyond generic facility taxonomies. Resolves who inside a facility is treating your patients and in which department. Standard commercial lists do not go here.
AMC Data Unlock
The 226 Academic Medical Centers in the US bill under institutional codes, which generates no signal in sample-based commercial data regardless of sample size. CareSet resolves facility claims to the treating physician, their department, and the associated patient cohort.
MarketView
Monthly market share reports by indication, treatment, geography, and brand, updated from 100% of Medicare FFS claims each month. New market-entrant adoption is visible from the first month of prescribing, not quarters later when commercial data catches up.
Regulatory, IRA and Part D
IRA Part D Spending
Current Part D gross expenditure by brand, identifying high-cost drug exposure and tracking spend trajectory under IRA negotiation timelines. Updated monthly from 100% of Medicare Part D claims. Claim-level, not modeled.
Biologic Discard Rebate
Claim-level data on discarded biologic medications by brand, for rebate management and regulatory compliance under HR 3684. The discard data comes directly from Medicare claims. No extrapolation, no modeling.
LIS and Catastrophic Coverage
Low-income subsidy population segmented by plan and geography. Supports field targeting, formulary strategy, and regulatory compliance in the catastrophic coverage phase. Updated monthly with a two-week lag from CMS.
The Depth of Our Expertise and Analysis
We understand how each disease actually progresses, where treatment decisions are made, and how therapy changes from one line to the next, across the specialties within each disease area, resolved to the level where treatment is actually chosen.
Every analysis is built from the Medicare Fee-for-Service census, NPI-level claims with 25+ years of history, which lets us follow patients and providers over time, not just count them in a snapshot.
The questions teams bring to us
Which physicians are actually managing our patients, and how do we reach the ones our commercial data misses?
We surface physician-level prescribing behavior, identify the doctors treating your patients, and reach the 10 to 25% of high-value prescribers that standard commercial lists miss.
Where will payers stand before we walk into pricing discussions?
We show the full payer landscape: formulary positioning, Part D coverage, restricted-account exposure, and plan-level utilization, so access strategy rests on claims data rather than assumptions.
What evidence will payers and clinicians actually trust?
We build evidence from adjudicated Medicare claims covering 100% of FFS beneficiaries and 40% or more of covered lives, complementing trial data with population-level proof.
How is our market moving, from pre-launch through market-share defense?
We size markets, plan launches, map patient journeys, and track competitive positioning, monitoring drug adoption and treatment shifts month over month.
Where should we act at each stage of launch and market evolution?
We connect treatment-sequencing analysis, high-prescriber identification, drug uptake, and site-of-care decisions into one commercialization view built on Medicare claims.
What is our exposure under IRA price negotiation and the Part D redesign?
We track Part D gross spend by brand, biologic discard liability, and low-income subsidy dynamics at the claim level, so regulatory and pricing teams can quantify exposure and plan ahead of each deadline.
Defining Medicare
CareSet's Medicare Fee-for-Service claims span inpatient, outpatient, physician, and pharmacy in a single dataset. With access to 100% of Original Medicare claims, Part A (Inpatient), Part B (Outpatient, including Institutional and Carrier Outpatient), and Part D (Pharmacy, including all MA pharmacy), CareSet captures the full record of care, including the hospital systems that do not resell their claims data. Because this is census data drawn directly from CMS, nothing is sampled or missing because a health system chose not to participate. If Medicare pays it, CareSet sees it.
That completeness lets CareSet map the full treatment pathway: where patients fall out before treatment initiation, which specialties and referral patterns shape decisions, and how site of care shifts by geography and payer. In complex areas such as rare disease, hematology, oncology, and immunology, that depth surfaces patterns that stay hidden in sampled data, including treatment switches, therapy discontinuations, and changes in prescribing behavior over time.
Part A — Inpatient
- Medical Benefits (UB-04)
- Hospital Site and CCN Names
- Rendering, Attending, and Surgery Physicians
- DRG, ICD-Procedure, Revenue Center, NDC, ICD
Part B — Outpatient
Part B (Institutional Outpatient)
- Medical Benefits (CMS-1450)
- Hospital Site and CCN Names
- Rendering, Referring, Attending, and Surgical NPIs
- HCPCS, Modifiers, Revenue Center, NDC, ICD
Part B (Carrier Outpatient)
- Medical Benefits (CMS-1500)
- Clinic / Practice / Free Standing Organization Names
- Performing and Referring NPIs
- HCPCS, Modifiers, ICD Codes
Part C — Medicare Advantage
- Private insurance alternatives to Original Medicare
- Payments processed by private insurers, not CMS
- Each MA plan operates separate claims systems
Part D — Pharmacy
- Prescriber NPI
- Pharmacy Identifier
- Pharmacy Chain, via NCPDP DataQ
- Captures prescriptions from both Medicare Advantage and Original Medicare