HIPAA Summit 10 Apr 7, 2005 1 Transaction-Based Business Intelligence Leveraging HIPAA to Gain Value from Transaction Data Joseph C Nichols MD Director of Healthcare Solutions
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HIPAA Summit 10Apr 7, 2005 1
Transaction-Based Business Intelligence
Leveraging HIPAA to Gain Value from Transaction Data
Joseph C Nichols MDDirector of Healthcare Solutions
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HIPAA and ‘Administrative Simplification’
If you liked ‘Tax Simplification’, you’re going to love ‘Administrative Simplification’!
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Gaining Value Overtime
+-
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The Ideal Standard
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The Ideal Standard
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The Ideal Standard
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The Ideal Standard
8
The Ideal Standard
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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?
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Sharing concepts – a shared ontology
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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.”
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The Standard Transactions
Claim Submission
Enrollment
Adjudication
Claim Acceptance
Accounts Payable
Authorization
Adjudication
Enrollment Disenrollme
nt
EnrollmentEligibility Verification
Claim Status Inquiry
Accounts Receivable
Authorization/ Referral
Claim Submission
PLANS/PAYERSPROVIDERS EMPLOYERS
270271
278
837
277
276
820834
835
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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
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15
16
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Getting to ‘Business Normalized Data’
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Abstracting to a higher level
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Getting to ‘Actionable information’
Defining the business problem Asking the right business questions Analyzing the results Defining potential actions Defining the value of action
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Getting to ‘Actionable information’
Defining the business problem Asking the right business questions Analyzing the results Defining potential actions Defining the value of action
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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
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Getting to ‘Actionable information’
Defining the business problem Asking the right business questions Analyzing the results Defining potential actions Defining the value of action
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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?
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Getting to ‘Actionable information’
Defining the business problem Asking the right business questions Analyzing the results Defining potential actions Defining the value of action
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Is there a common pattern in the reasons for denial?
Denials by Type
EligibilityInvalid codeCoverageMedical NecessityCCI
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What types of services are associated with denials?
$0 $10,000$20,000$30,000$40,000$50,000
Injections
DME
E&M Services
Lab
X-Ray
Surgical
Dollar Impact of Denials by Service
Dollar Impact
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Which payers are associated with denials?
0
50
100
150
200
250
PayerA PayerB PayerC PayerD PayerE
Claim Denial By Payer
Total ClaimsDenied
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Which providers are associated with denials?
0.00%
2.00%
4.00%
6.00%
8.00%
10.00%
12.00%
14.00%
Provider1 Provider2 Provider3 Provider4 Provider5 Provider6 Provider7
Percent Denials by Provider
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Which patients are associated with denials?
0
1
2
3
4
5
6
7
8
9
10
Pt 1 Pt 2 Pt 3 Pt 4 Pt 5 Pt 6 Pt 7 Pt 8 Pt 9 Pt 10
Count of Denials by Patient
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Getting to ‘Actionable information’
Defining the business problem Asking the right business questions Analyzing the results Defining potential actions Defining the value of action
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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
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Getting to ‘Actionable information’
Defining the business problem Asking the right business questions Analyzing the results Defining potential actions Defining the value of action
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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
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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
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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
Joe Nichols
HHS-OIG identified 12.1 Billion in improper payments in 2002OMB in 1996 estimated 10% or 100Billion per year in expenditures related to healthcare fraud and abuse now = to 500 million dollars perday
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Joseph C Nichols MDDirector of Healthcare Solutions
tel: 425.452-0632 | cell: 206.478-8227 | email: [email protected]. hipaadesk.com
Contact Information
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