Analytics for Claims Performance Management at a Leading Hospital

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Summary

Without flexible analytics, a leading hospital had a significant claims denial rate that resulted in loss of revenue.  Denial reasons include, but are not limited to, missing data field requirements, misclassified procedures and medical billing errors. Sagence helped build the analytics capabilities to improve the claims approval rate.

Challenge

Complex data flows, proprietary data retrieval languages and a lack of visualization capabilities limited a leading hospital’s ability to analyze their denied claims for the various services they provided. A lack of flexible analytical reports produced denials management strategies that were primarily driven by anecdotal evidence. This lead to workforce inefficiencies, payment delays and increased the likelihood that the denied transactions would be eventually be written off.

Solution

Sagence first incorporated denials management data from the hospital’s Electronic Health Record (EHR) into a Finance Data Mart, allowing for information to be easily accessed near real-time. Subject Matter Experts (SMEs) from finance and patient financial service groups were then interviewed to understand the business processes and data flows for billing, adjudication and general ledger posting stages of the denials management process.

Sagence designed and built a comprehensive suite of denials management dashboards with input from end-users that tracked transactions from posting to write-off processes. Features such as data exports, trend analysis and robust filtering were implemented in order to provide users with actionable insights.

Additionally, Sagence developed an enterprise data warehouse (EDW) utilizing an agile approach. The EDW enabled data integration from various sources and enabled the hospital’s growing reporting and analytical needs.

Results

As a result of the work accomplished by Sagence, the organization gained unprecedented insight into their claims data and overall claims performance. Initial review of the tools lead to the identification of quick win opportunities, leading to an immediate reduction in claims being written off for preventable reasons. Centrally located reports have set a precedent of having data driven conversations with both the hospital’s internal and external business partners. Denials management strategies and performance improvement opportunities can be tracked and pursued with more confidence. Furthermore, the information presented allowed for care managers to have informed conversations with insurance companies when negotiating policies or resolving issues with payors.

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