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The pitfalls of poor data management and how to prevent them

Data inaccuracies have always posed a threat of litigation and penalties, particularly if they can be found in the proper execution of bad data in an individual chart that compromises patient safety.

However, the brand new rules around price and coverage transparency introduced by the Centers for Medicare and Medicaid Services put in a new layer of risk involving patient data and patient interactions for both providers and payers.

Russ Thomas, CEO of Availity which just this week announced its acquisition of Diameter Health spoke with Healthcare IT News to go over how inaccuracies put hospitals and health systems at greater threat of litigation, government penalties and investigations, and significant administrative costs connected with correcting errors.

Q. Just how do data inaccuracies put doctor organizations at greater risk?

A. The brand new CMS regulations require providers and payers to help keep patients informed concerning the costs of care and their personal financial responsibility through the entire care journey. Furthermore, they might need providers and plans to get patient consent for the services and associated expenses.

The expenses reflected in the ultimate bill must align with those quoted before the encounter or procedure. Under these new rules, if patients aren’t informed or are informed inaccurately, the provider could become responsible from the financial standpoint.

These regulations put in a layer of complexity for providers and payers with regards to tracking and reporting financial data. For instance, this practice is easy with regards to a typical procedure, such as for example an annual visit (for instance, the price of the appointment is X, the individual co-pay is Y).

However, it becomes more technical when new needs are uncovered throughout a patient encounter. For instance, in case a patient presents in the ED in terrible pain, and some tests should be performed to diagnose the reason. Or, throughout a colonoscopy, in case a physician finds several polyps that must definitely be removed and tested. These costs can range wildly, in fact it is not necessarily possible to see the individual beforehand.

Accurate provider data is essential to ensuring alignment between your provider and medical anticipate specific members. The more technical the function, the more risk involved and the more challenging it’ll be to pinpoint an expected expense for the member.

Hospitals face the best degree of exposure in this environment due to the amount of unplanned medical activities they manage, but risk has increased over the board.

Q. There may be significant administrative costs connected with correcting errors. How come this?

A. If you believe about provider data specifically, there are specific elements which are an easy task to validate. For instance, you can easily know if Dr. Smith is really a female or male or whether she actually is an interior medicine physician or osteopathic specialist.

However, you can find other elements which are difficult to verify, particularly when it involves resource allocation in large, complex health systems. Tracking the locations where Dr. Smith is contractually in a position to see and treat patients is one particular elements.

That is becoming a growing problem as health systems continue steadily to expand their service offerings via acquisition. For instance, in case a hospital acquires Dr. Smith’s standalone practice, her office is currently among multiple facilities in a healthcare facility network. Dr. Smith’s contract may change consequently, enabling her to see and treat patients at other hospital-owned locations beyond her very own practice.

Monitoring where Dr. Smith will arrive and offer services is tricky in these instances as the healthcare industry currently does not have a standard solution to communicate the difference between contractually in a position to see patients versus actually seeing patients.

For instance, Dr. Smith may primarily see patients in location A, but can be contractually in a position to see patients in locations B, C, D and E. A health plan’s system might not be capable of differentiate between where Dr. Smith sees patients and where she actually is contracted to see patients.

If medical plan chooses to point that Dr. Smith is not any longer contracted to see patients in locations B through E, and Dr. Smith fills set for a provider 1 day at location B, then your incoming claim could possibly be incorrectly viewed by medical plan as a non-par claim, that is a lot more expensive.

These kinds of physician allocation errors can frequently be corrected on the trunk end, but new regulations declare that patients shouldn’t be in charge of solving these issues. Therefore, aligning this data is normally an extremely manual effort undertaken by providers and payers.

For instance, I spoke with a physician’s office recently, plus they have an FTE whose sole responsibility would be to ensure their provider contract data is aligned with the 10 insurance firms they use make it possible for accurate cost estimates and price transparency.

Q. You say that as healthcare tries to stick to new regulations, it faces tremendous operational challenges. What exactly are these challenges?

A. Among the challenges is how differences in patient profile can drastically change the expenses from the same procedure. For instance, a wholesome patient without comorbidities can likely get a colonoscopy at an outpatient center.

However, an individual with a condition such as for example hemophilia would want that same colonoscopy performed in the more expensive hospital setting due to the complications which could potentially arise. This variability makes providing accurate estimates complicated.

One method to potentially address this matter would be to provide best-case and worst-case estimates. Addressing the main point where these estimates could be made in real-time, so that an operation can safely continue whenever a complication arises minus the concern to be fined or not properly reimbursed, is key.

Also, as the regulations are well-intended, the truth is it really is probably unnecessary to really have the specified degree of price transparency for each and every encounter. We have to concentrate on probably the most problematic events those medical episodes that bankrupt people since they had no idea what their out-of-pocket costs will be.

It will be easier for the healthcare community to rally for this effort and eliminate most of the challenges connected with addressing variability in more routine scenarios.

Q. In light of most these problems and challenges, so what can doctor organizations do to mitigate risk and improve data management? How do they enhance the accuracy and currency of these data?

A. Most provider organizations don’t possess the same kind of contract with every insurance provider. Much of that is legacy-based. Provider organizations must proactively manage and align their contracts. There exists a large amount of vagueness of this type at this time. If providers understand the differences in all of their insurance contracts and update each appropriately, then it lessens the impact of variability.

Provider organizations should also understand the differences between their systems and the back-end systems leveraged by their contracted health plans.

They have to understand their payers’ capacity to cope with complexities such as for example determining in case a provider is contractually in a position to visit a patient in each location versus the way the provider is established within their directories. They have to know in case a payer system will categorize a claim as a par or non-par claim in virtually any of these locations.

Finally, provider organizations must make sure their very own data is clean, accurate or more to date. One of the primary complaints from CMS is that retired or deceased physicians still often arrive on directories. You can find solutions on industry which will help automate your time and effort of cleaning data.

These solutions can leverage transactional data and issue prompts asking in case a specific doctor continues to be with a particular provider organization. Or even, the perfect solution is can start a workflow to communicate this change to contracted health plans.

This capability is essential in reducing the administrative burden necessary to comply with the brand new price transparency regulations that concentrate on the association of physicians to location and the effect on cost.

Twitter:@SiwickiHealthIT

Email the writer:bsiwicki@himss.org

Healthcare IT News is really a HIMSS Media publication.

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