Products & Technology

The Great Claims Data Treasure Hunt

Effectively analyzing your billing and claims data can uncover big revenuegenerating and cashsaving opportunities.

Claims DataMining metrics — those quantifiable data jewels used to track and assess your business processes — is an ongoing treasure hunt that can bolster the success of your business. Data can lead you to financial health, helping you to better understand where your money is coming from, to discover new revenue streams and to uncover problems before they permeate your business.

However, instead of leading HME providers to new strains of business gold, much data remains raw and untapped for many providers.

“Having been in the industry for over 25 years and in and out of well over 100 provider sites implementing systems that capture data, I would venture to guess that at least 60 percent of data collected is not put to good use analyzing the success of business operations,” says Kimberly Commito, director of product management for Mediware Information Systems Inc. “Providers many times do not think outside of the usual box of reports offered to them in their software platforms and many platforms make it difficult to get to the data that is not offered up in the usual cookie cutter report offerings. As a result, day-today operations get in the way of using that data in a thoughtful way to gauge progress on business goals and to assist in identifying areas for improvement.”

While on-site with providers, Commito says she has asked them, “how many new referrals did you receive last month that you did not actually accept and why?” Many times, she says, providers do not realize that their given platform provides a mechanism by which they can collect this data, whether it is simply implementing that function or adding user defined fields to accomplish the goal.

“There is so much data available within an HME’s electronic billing system that is not being utilized to the fullest to help identify and engage key referral sources,” says Ryan Ball, director of VGM Market Data. “Tracking physician referral volume allows for the creation of engagement plans if you can identify a decrease or change in volume attributable to key physicians.”

Ball says patient contact information is also a largely untapped data resource for marketing purposes.

“Many HMEs don’t market additional products that could help the patient they are already serving,” he says. “CPAP resupply items or cash items like cleaners and additional masks are a great way to generate additional revenue.”

Melissa Wagner, senior consultant with Brightree LLC, says, “Simply put, data helps providers keep a financial and operational pulse on the business. By analyzing the data, you can provide visibility to areas of the business that may not be operating efficiently or may be contributing to unnecessary costs or decreases in cash flow, such as denials. In today’s reimbursement environment, any excess costs or decreases in cash flow can put the survival of the business at risk.”

Why Aren’t Providers Digging Deeper?

Phil Deschaine, marketing director of Universal Software Solutions Inc., says that the No. 1 reason HME providers are not using collected data to its fullest potential is that they don’t have the time to do the analysis and then articulate the right questions.

“In order to use their data effectively, a provider must first know what are the most significant questions to be asked about their operations, patients, payers, employees and so on,” he says. “Once the questions are defined and written down, extracting the data into useful reports, graphs and dashboards is very straight forward.”

For Wagner, providers’ lack of data collection is a simple matter of awareness.

“Providers should proactively ask questions of their software vendor as to how and where KPI [key performance indicators] data is readily available,” she explains. “Also, providers often fear that to get to the data needed, it will involve time-consuming running of reports and extensive manipulation of spreadsheets. There are advanced business management software solutions that can offer advanced tools to simplify and provide quicker access to reporting and dashboard formats.”

Ball says that providers have traditionally focused on patient care, so many are new to key sales and marketing strategies. He pointed out that multiple software platforms also make data tracking more difficult to use day to day. The goal, he says, should be to not just track key data points, but to enable sales and marketing to use that information in their daily duties.

“Data can and should drive business operations and decision making,” he notes. “HMEs that have a better understanding of their competitive landscape are likely to have more success than those not seeking out opportunities for greater efficiencies. Providers should ask themselves: ‘Who are my largest competitors? How many referral sources exist in my market? Who are the highest volume prescribers within my market?’ Answers to these are obtainable and should be used to plot sales and marketing engagement strategies.”

Diagnosis Data Gems

One of the big gems that a provider can uncover is the spots in its business where it can extend its revenue per customer. Taking the time to review customer-level data can help providers identify some serious cross-selling and upselling opportunities, according to Richard Mehan, president of HME software maker Noble House.

So, for instance, with patient groups that are regularly prone to specific types of comorbidities, there could be opportunities to determine which of those types of patients that a provider serves might need solutions for those comorbidities. Diabetic patients are a good example, Mehan points out. Some might need special footwear, or some might need knee braces, or incontinence supplies.

Those types of upselling opportunities can mean a lot, especially given that reimbursement on many diabetic supplies for not only Medicare but other payer sources leave the provider with paper-thin profit margins.

“Right now, everybody is looking to maximize the potential revenue out of a patient,” he says, citing the example of a provider that might have one a bid for diabetic supplies. “I believe that the consensus is there is no money in strips anymore. A box of strips costs, bare bone cost, is around $1.50, $3.00, right around there. Then you add in postage, processing fees and handling, and of course you got the audits. All of a sudden it’s a negative expenditure or revenue.

“If you look at each of the bid winners, they’re not making money on strips,” he continues. “They’re cross selling and they’re messaging their patient base for other lines of business, whether it be catheters, or braces. They establish a rapport and a relationship with their customer base. With the next box of strips that the patient receives, there is a slip in there for certain patients about braces, or other products that [the provider is] expanding into.”

Claims data is where providers can find those sorts of opportunities for cross-selling and upselling. All it takes is for a physician diagnosis code to present providers with an opportunity to generate a report on patients with similar ICD-10 codes.

“When providers receive a doctor’s order form, and the information for a specific patient on there includes the diagnosis codes that the physician is labeling a patient with, the provider can then drill into its patient base on that specific diagnosis code,” Mehan explains. “If there’s any other diagnosis codes that a physician presents, they could drill into that data. … For each CPT code, there is a a matrix of supporting diagnosis codes. If any of them overlap, then just drilling into your data would afford you a whole new realm of prospects or customers.”

This approach of correlating patient purchase habits or probable comorbidities against diagnosis code might uncover a whole new line that providers could add. Providers just want to make sure that they are playing by Medicare’s rules when it comes to reimbursable items.

“As long as the products are not under competitive bidding and the door is still open for them to be able to provide those products,” Mehan advises. “Medicare is slowly but surely tightening the noose on them and it’s becoming next to impossible to go into certain lines of business if you’re not a bid winner.”

Digging Deeper

A common difficulties in naming the variables for digging deeper into provider data is that companies have operational differences, goals and niches. Therefore, the nature of what you are looking for may depend on how well a company understands its own business, customer demographics, product sales, etc. Simply put, one provider’s data treasure may not have the same level of appeal to another provider.

“Every aspect of a provider’s business can be improved with better data reporting and analysis,” Deschaine says. “This includes everything from order intake to posting payments. For example, by doing an inventory turnover analysis, a provider can make an intelligent decision about which items they should stock in their warehouse and which items should be ordered through a third-party fulfillment partner like McKesson. Only by having this data on hand can a provider make a sound decision on this and other aspects of their operations.”

However, Deschaine warns that because providers have their own unique market niche, which can be defined by a specialty, customer base, geography, etc., it is essential for providers to formulate an initial analysis that allows them to articulate the questions that data analysis can answer for them.

“Our experience at Universal Software Solutions is providers are going to find their own data gems that will be unique and valuable to their distinctive HME operations,” he explains.

Mining Referral Data

Another way to find data gems is through referral source management. Seth West is the Director of Marketing and Communications for PlayMaker CRM, a partner of the VGM Market Data Division. The PlayMaker CRM system offers business-to-physician management. PlayMaker, designed specifically for post-acute care companies, including HMEs, offers providers a mobile app that helps them manage their business-to-physician relationships and a way to identify high-value physicians using integrated market intelligence data that can be purchased. West says this service allows for:

  • Real-time order data to flow down to sales reps in the field, which wi ll let them respond to new orders.
  • Analysis of existing customers to understand where the business is coming from, which allows for the identification of trends and the ability to focus on the highest value accounts.
  • Market intelligence data to reveal new opportunities based on claims data for their market.

“Using data mining can provide details as to specific staff that may have been involved in a referral processed from intake to confirmation that was lacking the proper criteria for a clean claim,” Wagner explains. “Specifically, the lack of a commitment to software training, especially in which the software offers functionality to assist with notifying of missing data. Investing in training can provide a valuable return on investment if the right tools in the software are accessible to be used to prevent denials and subsequent audits.”

She also says that examining referring patterns by practitioners can offer data on the quality of referrals received. This process can assist with educating physicians on payer guidelines with the goal of saving both the provider and physician time and resources with medical documentation requests.

Ball pointed out that using your data to find out which patients could use a resupply program that presents them with options above and beyond what is reimbursed by insurance is a great way to grow incremental revenue.

“You can’t measure success without tracking referral volume,” he says. “By understanding your relationship with key referral sources, providers have additional opportunities with physician offices to truly be a partner in the management of the care of patients in need of HME equipment, rather than just an equipment supplier.”

Commito says that data mining starts with the evaluation of features and functions that your software offers. She suggests that providers that may have not had the time previously or may have since forgotten the full features of their software since initial implementation should now review the release notes or manuals provided to ascertain if there is a feature that was not critical to basic operations when going live on the application. Leveraging these features now could get you to the next step in using your application as a tool to support your business objectives.

“In addition, reaching out to your vendor to supplement staff training from time to time is a good investment,” she says. “Too many times organizations cut funds to invest in educating their staff in new features and functions that are available on the tools they use day to day to successfully manage their responsibilities. Some vendors offer free training and training resources that can assist here — so just ask. If you need a deeper level of focused training, then investing in that training can support efforts to continually improve your operation by leveraging the tools in place.

“Understanding the financial health and well-being of a company is critical to the ongoing success for any provider,” Commito continues. “Reports and analytics should be leveraged to their fullest for this purpose. Analytics, data mining and reporting can assist in identifying areas for improvement in various operational processes, such as number of referrals processed, deliveries completed successfully, inventory turns and management. Assessing and evaluating cost of goods and inventory management are critical to any HME provider. Tracking of patients, clinical progress and outcomes on key therapies provided can support accreditation, marketplace differentiation and overall patient satisfaction.”

This article originally appeared in the May 2017 issue of HME Business.

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