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Leveraging Your Good Data

Effective revenue cycle management turns on the accuracy of the information being analyzed.

Today's healthcare organizations are awash in electronic data.

Our subspecialty group practice, Texas Retina Associates (TRA), is no exception. We use electronic health records (EHRs), an electronic practice management (PM) system and numerous health information technology (HIT) systems that are continually capturing information entered at our 13 locations in the Dallas/Fort Worth region.

Managing all of the data inputs and outputs from insurance checks, EHR and thousands of line items in your PM can seem overwhelming. Having well-trained staff members along each step of the way allows us to ensure we are aggregating and leveraging "good data." This process helps us identify efficiencies and allows us to measure our productivity compared to other practices like our own.

Performance Analyses
Much of the data needed to conduct this performance analysis is easily accessible and right at our fingertips in our existing HIT systems and can be automatically extracted and analyzed with the right modification tools. This process allows us to obtain annual financial and operational benchmarks. The other information for comparisons against peer practices regionally and nationally can require some searching. By reaching out to other similar practices across the country, and through MGMA research, you can compile enough relevant benchmarking data to perform reliable analysis.

Conducting these type of analyses can help you understand how to improve your coding, billing and practice operations. Perhaps more importantly, for us it has also helped us to begin preparing for the industry's emerging shift to value-based payment. Eventually, many payers will base more of our reimbursement on our providers' care quality and our operational efficiency compared to other similar practices. By learning more about our performance now, we can avoid surprises in years ahead when payers start conducting their own data analysis. Moreover, this insight has helped us increase our current fee-for-service revenue by reducing our rejection rate and days in A/R and ensuring we are reimbursed our maximum contractual amounts.

SEE ALSO: Looking Into the Crystal Ball

Healthcare organizations should begin their performance analysis by reviewing their own claim and remittance statements. The data captured and analyzed from these two items alone provides a wealth of information about billing and collections performance. These documents can also offer insight into clinical quality based on the practice's diagnosis and procedural coding in the claim, but also feedback from the payer, such as adjustments, included on the remittance. Before organizations start analyzing claims and remittance data, however, they need to ensure they have captured and are analyzing "good" data. If the practice has a high rejection rate, for example, then it likely has a data accuracy problem.

Ensuring Data Accuracy
At TRA, ensuring accurate data begins before the patient appointment. We perform electronic batch eligibility pre-certification, which is significantly more efficient than our previous phone-driven eligibility determination process. For the past few years a busy clinic day at TRA can mean a single physician seeing more than 50 patients per day in many of our offices.  With this much volume we saw the need to improve the manual process of calling every insurance company to check benefits. 

Today, we automate our eligibility and benefits process as much as possible which allows the business office team to focus on the finer details such as obtaining pre-authorizations, referrals, identifying high-deductible plans and helping patients who may need financial assistance. We now determine eligibility and benefits a week in advance of patients' appointments; identify inaccuracies in health plan, patient or other information; and populate the corrected, accurate data back into our systems for later analysis.

After the appointment, it is crucial for claims scrubbers to review each claim-whether professional or institutional-to detect potential errors or irregularities prior to submittal. This way practices decrease the chances of the claim being rejected or denied by the payer. The scrubber can also help determine the sources of inaccurate data within the practice, such as a particular physician, coder, or simply a common data-entry error.  

Since payers often have their own unique submittal rules, practices will need to create custom software edits within the claims scrubber to ensure prompt and accurate adjudication. These edits in addition to the Centers for Medicare and Medicaid Services' (CMS) National Correct Coding Initiative and Local Coverage Determination edits will help the claims scrubber detect the most common and relevant errors. At TRA, creating these custom edits, some of which were automatically developed by our EHR, clearinghouse and claims scrubber vendor, helped us better understand our largest commercial payers' coding requirements, improving our clinical documentation and our first-pass submittal rate.

Making Sense of Good Data
Once you have "good" data in your system, you can begin comparing your financial and operational performance against similar practices through benchmark surveys from MGMA. By amassing enough benchmark data, we began generating reports using the accurate, or "good" data, compiled from our claims and remittances.

Using analytic tools from our practice management system and Navicure® ClaimFlowTM, our clearinghouse solution, we examine several operational performance indicators, including productivity, claims and payments. Some of the reports examine the number of encounters and procedures per physician; new patient referrals, contractual reimbursement, lag time from claim submittal to payment; and factors that contribute to claim rejections and appeals.

Likewise, on an ongoing basis, we analyze our practice's A/R, revenue and costs. Average days in A/R, average collections per patient and payer and operating cost per patient, are just a few of the metrics we continue to compare against the peer benchmark data. For a quick, high-level overview of your practice's performance, one method is to group your patient care revenue into subsets, such as new and established patients, surgeries, labs and other grouped procedures your practice may be performing to see a clearer picture of exactly what makes up your patient care revenue. This allows the ability to compare against prior periods, but when doing so, it's important to account for any changes to fee schedules or contracts, in addition to any physicians who've recently joined or left the practice to ensure a valid comparison.

We also have our PM system automatically and continually extract these data sets so at a moment's notice we can review our current performance against earlier time periods.

"Ensuring accurate data begins before the patient appointment."

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Future-Looking Analysis
While this data analysis is helping our practice's revenue cycle run more smoothly and detect operational and financial issues, the larger goal is to prepare TRA for the future. The operations efficiency data, in combination with positive clinical outcomes and patient satisfaction survey results, are what physician practices will need to share more often in the coming months and years with patients, payers and provider partners, including those affiliated with accountable care organizations.

Achieving higher clinical quality with lower costs than national or regional benchmarks is exactly what payers are rewarding under value-based reimbursement programs. Practices that can demonstrate this performance data now will likely be more attractive to payers and will have a better chance in the future at negotiating more favorable contracts.

Our practice's efforts toward improving data analysis began by simply assessing and capturing the data that we were already sending and receiving daily through our claims and remittances. By establishing processes and implementing tools to ensure that data are accurate and automatically analyzed, we feel we are well positioned to begin the next phase our practice's journey.

Shawn Harkey is director of financial services at Texas Retina Associates in Dallas.

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