Pitfalls of poor data management – and how to avoid them

Data inaccuracies have always posed a risk of litigation and penalties, especially when they come in the form of bad data in a patient record that compromises patient safety.

However, new rules regarding price and coverage transparency introduced by the Centers for Medicare and Medicaid Services add a new layer of risk involving patient data and patient interactions for providers and payers.

Availity CEO Russ Thomas – which just this week announced its acquisition of Diameter Health – spoke to Health Informatics News discuss how inaccuracies expose hospitals and healthcare systems to increased risk of litigation, government sanctions and investigations, and the significant administrative costs associated with correcting errors.

Q. How do data inaccuracies put healthcare provider organizations at greater risk?

A. The new CMS regulations require providers and payers to keep patients informed of the costs of care and their personal financial responsibility throughout the care journey. Additionally, they require providers and plans to receive patient consent for services and associated expenses.

Costs reflected in the final invoice must also match those quoted prior to the meeting or proceeding. Under these new rules, if patients are not informed or are informed inaccurately, the provider could end up financially liable.

These regulations add a layer of complexity for providers and payers when it comes to tracking and reporting financial data. For example, this practice is simple when it comes to a standard procedure, such as an annual visit (eg, appointment cost is X, patient co-payment is Y).

However, it becomes more complex when new needs are discovered during a patient encounter. For example, if a patient presents to the emergency room with excruciating pain, and a series of tests must be performed to diagnose the cause. Or, during a colonoscopy, if a doctor finds multiple polyps that need to be removed and tested. These costs can vary enormously and it is not always possible to inform the patient beforehand.

Accurate provider data is important to ensure alignment between the provider and the health plan on specific members. The more complex the event, the more risk it entails and the more difficult it will be to identify a planned expense for the member.

Hospitals face the highest level of exposure in this environment due to the number of unplanned medical activities they handle, but the risk has increased across the board.

Q. There can be significant administrative costs associated with correcting errors. Why is it?

A. If you think specifically about supplier data, some things are easy to validate. For example, it is easy to know if Dr. Smith is a man or a woman or if she is an internal doctor or a specialist in osteopathy.

However, there are other elements that are difficult to verify, especially when it comes to resource allocation in large, complex health systems. Tracking where Dr. Smith is contractually able to see and treat patients is one such element.

This is becoming a growing problem as health systems continue to expand their service offerings through acquisitions. For example, if a hospital acquires Dr. Smith’s stand-alone practice, his practice is now one of many locations in the hospital network. Dr. Smith’s contract may change accordingly, allowing him to see and treat patients at other hospital-owned facilities outside of his own practice.

Keeping track of where Dr. Smith will show up and provide services is tricky in these cases, as the healthcare industry currently does not have a standard way to communicate the difference between the contractual ability to see patients and the ability to actually see patients.

For example, Dr. Smith can primarily see patients in location A, but is also contractually able to see patients in locations B, C, D, and E. A health plan’s system may not have the ability to tell the difference between where Dr. Smith sees patients and where she is hired to see patients.

If the health plan chooses to indicate that Dr. Smith is no longer under contract to see patients in locations B through E, and Dr. Smith is replacing a provider one day in location B, then the incoming request could be frowned upon by the health plan as a claim without participation, which is much more expensive.

These types of physician assignment errors can often be corrected in the end, but new regulations say patients shouldn’t be responsible for fixing these issues. Therefore, aligning this data is usually a very manual effort undertaken by providers and payers.

For example, I recently spoke with a medical practice, and they have an ETP whose sole responsibility is to ensure that their vendor contract data is aligned with the 10 insurance companies they work with for enable accurate cost estimates and price transparency.

Q. You say that as healthcare attempts to comply with new regulations, it faces tremendous operational challenges. What are these challenges?

A. One of the challenges is how differences in patient profiles can drastically alter the costs associated with the same procedure. For example, a healthy patient with no comorbidities can probably receive a colonoscopy at an outpatient center.

However, a patient with a medical condition such as hemophilia would need the same colonoscopy performed in the most expensive hospital setting because of the complications that might arise. This variability makes it difficult to provide accurate estimates.

One way to solve this problem is to provide best and worst case estimates. Getting to the point where these estimates can be made in real time, so that a procedure can safely continue when a complication arises without fear of being fined or not being properly reimbursed, is essential.

Also, while the regulations are well-intentioned, the reality is that it’s probably not necessary to have the specified level of price transparency for every encounter. We need to focus on the most problematic events – those medical episodes that put people out of business because they had no idea what their outgoings would be.

It would be much easier for the healthcare community to buy into this effort and eliminate many of the challenges associated with managing variability in more common scenarios.

Q. In light of all these issues and challenges, what can healthcare provider organizations do to mitigate risk and improve data management? How can they improve the accuracy and timeliness of their data?

A. Most provider organizations do not have the same type of contract with each insurance company. Much of this is based on inheritance. Provider organizations need to proactively manage and align their contracts. There is a lot of confusion in this area at the moment. If providers understand the differences in each of their insurance contracts and update them appropriately, this mitigates the impact of variability.

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

They need to understand their payers’ ability to deal with complexities such as determining if a provider is contractually able to see a patient in each location versus how the provider is configured in their rosters. They need to know whether a payer system will classify a claim as a participating or non-participating claim in one of these places.

Finally, provider organizations must ensure that their own data is clean, accurate, and up-to-date. One of CMS’s biggest complaints is that retired or deceased doctors still often appear in directories. There are solutions on the market that can help automate the data cleansing effort.

These solutions can leverage transactional data and issue prompts asking if a specific doctor is still with a specific provider organization. If not, the solution can initiate a workflow to communicate this change to contracted health plans.

This capability is critical to reducing the administrative burden required to comply with new price transparency regulations that focus on linking physicians to location and cost impact.

Twitter: @SiwickiHealthIT
Email the author: [email protected]
Healthcare IT News is a HIMSS Media publication.

Comments are closed.