Transaction-Based Business Intelligence Leveraging HIPAA to Gain Value from Transaction Data Joseph C Nichols MD Director of Healthcare Solutions HIPAA Summit 10 Apr 7, 2005 1
HIPAA and Administrative Simplification If you liked Tax Simplification, you re going to love Administrative Simplification! 2
Gaining Value Overtime + - 3
The Ideal Standard 4
The Ideal Standard 5
The Ideal Standard 6
The Ideal Standard 7
The Ideal Standard 8
The Challenge of Information Sharing Agreeing to the container for the information Agreeing to values Agreeing to the scope of the content Sharing conceptual definitions Did we follow our agreements? How do I use this information in my own environment? 9
Sharing concepts a shared ontology 10
What is Transaction-based Business Intelligence? The use of standard healthcare transactions to provide actionable information about the data that is entering and leaving an organization, independent of the sending or receiving systems. 11
The Standard Transactions PROVIDERS PLANS/PAYERS EMPLOYERS Eligibility Verification 270 271 Enrollment 834 820 Enrollment Disenrollment Authorization/ Referral 278 Authorization Adjudication Claim Submission Claim Submission Claim Status Inquiry 837 276 277 Claim Acceptance Adjudication Accounts Receivable 835 Accounts Payable 12
The Promise of Standard Transactions A closer step to shared concepts A clear definition of the containers A clear definition of the values A clear definition of the scope of the content A process for validating our agreements 13
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Getting to Business Normalized Data 17
Abstracting to a higher level 18
Getting to Actionable information Defining the business problem Asking the right business questions Analyzing the results Defining potential actions Defining the value of action 19
Getting to Actionable information Defining the business problem Asking the right business questions Analyzing the results Defining potential actions Defining the value of action 20
Business Scenario A provider clinic has identified an increasing trend in claim denials The denials are resulting in a significant impact on cash flow The problem does not appear to be related to an issue with the electronic submission of claims 21
Getting to Actionable information Defining the business problem Asking the right business questions Analyzing the results Defining potential actions Defining the value of action 22
Business Questions Is there a common pattern in the reasons for denial? What are the most common types of services that are associated with denials? Which payers are most frequently associated with denials? Are these denials more common with a specific rendering provider? 23
Getting to Actionable information Defining the business problem Asking the right business questions Analyzing the results Defining potential actions Defining the value of action 24
Is there a common pattern in the reasons for denial? Denials by Type Eligibility Invalid code Coverage Medical Necessity CCI 25
What types of services are associated with denials? Dollar Impact of Denials by Service Surgical X-Ray Lab E&M Services Dollar Impact DME Injections $0 $10,000$20,000$30,000$40,000$50,000 26
Which payers are associated with denials? Claim Denial By Payer 250 200 150 100 Total Claims Denied 50 0 PayerA PayerB PayerC PayerD PayerE 27
Which providers are associated with denials? Percent Denials by Provider 14.00% 12.00% 10.00% 8.00% 6.00% 4.00% 2.00% 0.00% Provider1 Provider2 Provider3 Provider4 Provider5 Provider6 Provider7 28
Which patients are associated with denials? Count of Denials by Patient 10 9 8 7 6 5 4 3 2 1 0 Pt 1 Pt 2 Pt 3 Pt 4 Pt 5 Pt 6 Pt 7 Pt 8 Pt 9 Pt 10 29
Getting to Actionable information Defining the business problem Asking the right business questions Analyzing the results Defining potential actions Defining the value of action 30
Potential Actions Eligibility processes are tightened a the time of scheduling Coding procedures are changed Communication with patients around coverage issues Educate individual providers about coverage issues 31
Getting to Actionable information Defining the business problem Asking the right business questions Analyzing the results Defining potential actions Defining the value of action 32
Defining the Value of Action Measurable improvement in cash flow that can be specifically attributed to actions Improved patient relationship Less rebilling and distractive denial management 33
Advantages of Transaction-based Business Intelligence Gold standard for inbound and outbound transactions Minimal dependencies on legacy integration Limited IT resource requirements Enhanced opportunities for benchmarking 34
Advantages of Transaction-based Business Intelligence Business intelligence independent of the data source Leverages existing compliance related investments Provides an auditing source independent of legacy systems for transaction related controls for inbound and outbound transactions to support Sarbanes-Oxley and other corporate compliance reporting requirements 35
Contact Information Joseph C Nichols MD Director of Healthcare Solutions tel: 425.452-0632 cell: 206.478-8227 email: josephn@edifecs.com www.edifecs.com www. hipaadesk.com 36