Products & Technology
The Great Claims Data Treasure Hunt
Effectively analyzing your billing and claims data can uncover big revenuegenerating and cashsaving opportunities.
- By Joseph Duffy
- May 01, 2017
Mining 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
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
“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
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
“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.”
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
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.