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The Claims Data Dilemma:
4 Things to Consider

By Dr. Martin Lustick

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Blog Home    The Claims Data Dilemma:
4 Things to Consider
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In April, NextGen Healthcare’s leadership team met with leaders of provider organizations representing a range of specialties and geographies. One of the themes that came through loud and clear was their ongoing struggle to obtain claims data from their payers. As providers continue their efforts to navigate alternative payment models (APM) their need for global claims data becomes a more pressing issue.

Why claims data is important to providers

Many providers are still in a position with little or no downside risk. Even in this early stage claims data is important. Many of the quality metrics require claims data in order for providers to fully understand their performance. It’s common that services not performed by primary care doctors will not be fully captured in their own EHR. Colonoscopy, mammography, and diabetic retinal screening are good examples of this phenomenon.

Perhaps less obvious is the need for claims data in the context of gainsharing arrangements even when there is no downside risk. Providers in this setting need to manage costs in order to maximize their upside potential and can’t really do that in that absence of a timely, robust claims feed from the payer. Learning how to identify and act on opportunities apparent in claims data will both maximize current opportunities and prepare provider organizations for downside risk in the future.

Limitations on its value

Claims data, at its best, is generally three months behind point of care in terms of giving a clear picture of utilization and cost. This is because it takes that long for an adequate percentage of the claims from a given month to be submitted to the health plan. As a result, claims data is useful for planning and for retrospectively evaluating performance, but has limited value in real time. For providers entering contracts with downside risk, a claims database that shows utilization and cost trends as well as performance against regional and national benchmarks can be extremely helpful in identifying opportunities and prioritizing resource allocation for planned interventions. This same database can also serve as a critical supplement to real time data that providers obtain through their EHR. A population health platform enables an integrated view that brings together claims data, EHR data, and other information sources such as a health information exchange (HIE). That approach is foundational to any organization that is committed to APMs that include downside risk.

Obstacles to obtaining the data

Given the obvious value of claims data to providers entering into APMs, it’s not surprising that they are frustrated by challenges related to obtaining this data. Two categories of issues explain the majority of obstacles. First is the willingness (or unwillingness) of payers to share data. In the absence of regulatory requirements, it’s not surprising that, across commercial payers, there is significant variability. Even for payers willing to share there is typically a minimum number of their members that must be attributed to that provider in order for them to be amenable to do this.

This issue of attribution is the second major obstacle. In most APMs, attribution is either based on primary care utilization only or, for a specialist participating in bundled payments, is based on the specialty provider that performs the index service for that bundle. The payers have employed methodologies that studiously avoid the same patient being attributed to two different providers. In this context payers are generally unwilling to provide full claims feeds to any provider other than the attributed primary care organization. The result is that even if a provider is rendering services to a patient, if that patient is not attributed to them, some data may be excluded and the provider has only a limited view to the breadth of care the patient is receiving outside their office.

Behavioral health (BH) is challenging the status quo

This unwillingness to duplicate attribution is particularly problematic for BH providers attempting to both manage and demonstrate their value. The current Medicaid waiver proposal in New York State may help overcome this critical logjam. It represents an important attempt to break the mold and make attribution reflect the integrated nature of health services. This proposal includes specific language describing “…differential attribution methodologies utilizing a member’s primary behavioral health provider (e.g., Article 31, 32, 36, or integrated clinic) or Health Home focusing on individuals with behavioral health diagnoses, rather than a primary care only attribution methodology.” If this proposal holds, managed care organizations (MCOs) will be required to attribute members with BH services to both primary care and BH providers. That opens the door for BH providers, perhaps for the first time, gaining access to all claims data on their patients, enabling a truly integrated view of their patients’ healthcare.

As providers face the challenges of caring for their patients in the midst of rapid change in both the way care is delivered and the way it is paid for, obtaining claims data often represents a frustrating distraction in their day-to-day struggles. That said, if there is a sustainable future for alternative payment models, enabling providers to integrate robust claims feeds with their EHR and other sources of patient information will be foundational to success.

For more information on NextGen® Healthcare’s solutions and resources, visit our website.


Dr. Martin Lustick

Senior Vice President, NextGen® Advisors

Dr. Martin Lustick is a principal and senior vice president with NextGen Healthcare focused on supporting provider organizations in their successful transition from volume to value-based care…

Dr. Martin Lustick is a principal and senior vice president with NextGen Healthcare focused on supporting provider organizations in their successful transition from volume to value-based care.

Dr. Lustick earned a BA in History from Cornell and an MD from Columbia. After completing his pediatric residency at Children’s Hospital National Medical Center in Washington, DC, he was in clinical practice for 17 years with Kaiser Permanente of the Mid-Atlantic States. While there, Dr. Lustick held various management and leadership roles, including chief operating officer for the 800-physician medical group. He oversaw development of their hospitalist program, population health capability, and open access delivery model.

Dr. Lustick then served as chief medical officer for ThompsonHealth—a small health system in Canandaigua, NY—where he provided clinical oversight for hospital, SNF, nursing home, IT, and out-patient physician practices.

In 2005, Dr. Lustick assumed the role of SVP & CMO for Excellus BCBS which covers 1.6 million lives comprised of Medicare, Commercial, and Medicaid. In his 13+ year tenure there he led a variety of strategic initiatives, including a patient-centered medical home program which served as the foundation for the plan’s value-based payment strategy. He also led the implementation of an automated authorization program for care management services, development of a clinical quality improvement strategy, and creation of innovative programs in management of low back pain, screening and prevention, opioid addiction, and chronic disease management.

Dr. Lustick has also been very active in the community, serving on boards and committees confronting issues such as: healthcare capacity planning, Health Information Exchange, mental health, substance use disorders, social determinants of health, and childhood obesity.

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The financial and clinical challenges you face now are evolving rapidly. Here are resources, solutions, and ideas we think will help.

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