There’s a story in your claims data. The key is knowing how to access it. Find out how to get the most out of this valuable information.

There’s a story in your claims data.

From the moment a patient walks into a healthcare facility or logs on to a telemedicine visit through the services they receive from the medical team, your organization is gathering critical information from patients that drive each claim. From there, this claims data becomes an invaluable source of truth, helping your organization monitor, trend, and identify clinical and financial risks and opportunities– that contribute to the organization’s overall success.

Claims data is at your organization’s fingertips. But how can you grasp it and use it more effectively?

Why is claims data important?

Payors, quality improvement organizations, and government entities all use claims data. It’s important, therefore, for provider organizations to effectively review and use their own data. This allows them to stay up to date on what’s going on in their own organizations so that the claims information they’re sending out is as accurate as possible.

Accuracy of the data housed within 837 claims is essential because of the critical role these claims play in the timely reimbursement of claims and in prevention of claims denials, which have increased substantially. Providers can use claims data in many ways, including: 

• Identifying patient risks through analyzation of care delivered
• Optimizing reimbursement
• Being more proactive in implementing changes to processes
• Developing predictive modeling to aid in risk stratification
• Improving care coordination
  
  

In addition, auditors use claims data throughout their audit processes. For example, auditors use claims data during risk assessments to identify high-risk areas. Auditors also can incorporate claims data into audit plans, where it can be assessed to help improve processes. Further, auditors can use the data in post-audit follow-ups to test effectiveness of new processes. Finally, data analytics can be used to continuously monitor areas and make sure previously identified – or new – risks do not emerge over time.

Data analytics + claims monitoring: A powerful combination

Through data analytics, organizations can leverage claims data to gain powerful insights into numerous areas, including payments, quality, and risks. The following examples illustrate how Kodiak customers have effectively used the data to make positive changes to their claims processes.

Example 1: Improving coding by provider and specialty

A provider group was struggling to access meaningful data that could help it identify outlier providers in its targeted evaluation and management audits. The internal audit team was performing random samples of providers, but these were not identifying potential areas of concern. 

Kodiak’s team and the provider group discussed how Kodiak could use the organization’s claims data to quantify and stratify its provider data by specialty. That data could then be compared with Centers for Medicare & Medicaid Services bell curves to identify outlier providers based on specialty. This would allow the provider group’s internal auditors to focus their coding review efforts on those providers who were coding higher or lower than expected according to the bell curves. That also would allow them to eliminate the need to spend as much time on those providers who were in line with the bell curves.

Using this approach, the provider group customer reviewed the records of the providers who were coding higher and determine whether the documentation supported the coding or, if not, could provide education to the providers about why they weren’t meeting the requirements for coding at certain levels.

For those providers on the lower end of the bell curves, the organization reviewed the records to determine if there were services provided that weren’t being fully documented and then educate those providers so they could get paid appropriately for the services, ultimately preventing underbilling. In addition to data comparing providers by specialty to the CMS bell curves, Kodiak provided the customer bell curves based on their organizational performance. This allowed internal auditors to see when providers of the same specialty were on the high or low sides of the coding bell curve.

The data now allows the organization to trend an entire specialty against the CMS bell curves and against themselves, enabling them to more thoroughly analyze coding by specialty or provider to see where improvements can be made or if provider education is needed. The provider group continues to use the data to access insights they couldn’t see prior to this more targeted approach to its claims review process.

Example 2: A reimbursement opportunity in status changes

Kodiak’s internal audit specialists performed a claims monitoring analysis and worked with the internal audit team at a nonprofit community hospital to better understand patient status trends. Using data analytics, a Kodiak audit determined there was a trend of higher numbers of inpatient cases and lower number of observation cases within the hospital.

To gain further insight into this risk area, Kodiak’s specialists selected a sample of claims to audit observation cases. During the audit, the specialists identified gaps in the hospital’s processes.  They also identified a significant reimbursement opportunity – $875,000.

In addition to providing the hospital customer with a summary of its findings, including a list of process gaps, Kodiak also helped the organization develop baseline metrics that, through ongoing performance monitoring, allow the organization to continuously determine if implemented process improvements remain effective.

Ready to elevate your claims management?

Claims data can be a valuable resource to support the decision-making and process improvements that drive your organization’s clinical and financial success, but only if you’re leveraging it correctly. Understanding how to get the most out of your data is crucial. For support navigating and getting insights out of your data that will help improve your organization’s processes and maintain sustainability, reach out to Kodiak’s specialists today.