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Podcast Library > NextGen Advisors Podcasts > The Untapped Value of Adjudicated Claims Analytics

May 21, 2021

The Untapped Value of Adjudicated Claims Analytics

There is growing interest in the use of multi-sourced data analytics to support practice’s success in value-based contracts, particularly the use of adjudicated insurance claims.

Analysis of adjudicated claims allows practices to gain cost and utilization insights essential for reducing the cost of care while enhancing its quality.  This week’s guest, Jamie Hayslip, senior director for population health solutions with NextGen Healthcare, shares his deep knowledge of adjudicated claims analytics as part of a comprehensive population health strategy.

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Transcript

Dr. Betty Rabinowitz:

Hello, and welcome to our podcast. I'm Dr. Betty Rabinowitz, NextGen Chief Medical Officer, and one of the principles with the NextGen advisors. With me today is a special guest Jamie Hayslip, who is a senior director for Population Health Solutions with NextGen Healthcare. Welcome Jamie.

Jamie Hayslip:

Thanks Dr. Betty. Good to be here.

Dr. Betty Rabinowitz:

Nice to have this time with you, Jamie. Jamie, can you tell us a little bit about your role in the Population Health team and a little bit about your experience in this area?

Jamie Hayslip:

Sure, sure, Dr. Betty. Yep. I work in what's called the Solutions Division of NextGen Healthcare specifically in the population health area. So I'm really responsible for the product development for some of our population health analytics tools and software applications that we develop. So I try to stay in tune with the marketplace and our current clients, and hopefully future clients and what their needs are, and guide the development teams to make sure that we're meeting the expectations and the demands of the marketplace, specifically in population health and population health analytics. It's an area that I've been involved in for quite some time. Before coming to NextGen a couple years ago, I worked at an independent practice association in Rochester, New York, and spent a lot of time working with data, claims data included, to help drive value-based care programs.

Dr. Betty Rabinowitz:

Terrific, terrific. I think these insights and expertise will serve you, obviously, well in today's conversation, but are tremendously helpful to our clients on a daily basis. There's a growing interest across the country overall in analytics to support a practice's success in value-based contracts. We're seeing particularly an increased interest in the use of adjudicated insurance claims in that process. And I was wondering before we get started, if you could tell us a little bit about why the interest in adjudicated claims? When you have them, what magic happens? What can you do with them? What does it allow a group to have happen if you can get adjudicated claims analytics?

Jamie Hayslip:

Sure. And maybe I'll even start by what are adjudicated claims, or what exactly are we talking about? So in this case, if we think about the reimbursement process for providers, providers and provider groups might be familiar with submitting claims or really the requests for payment to the insurance payers, and that's usually what comes out of their practice management or revenue cycle systems. But the payers really take those and have a full kind of validation and kind of payment assignment process on their end. And that's really what we mean by when we talk about adjudication, is that payer process that validates the claims as legitimate, and also signs the proper reimbursement amount as it relates to things like the benefit coverage for the patients, and also the agreed payment rates that the payers have with the providers. So that after that kind of process on the payers end of things, really, we have a true representation of the actual costs of the healthcare services. And that information is very powerful and allows us to do financial analytics as well as some other analytics that relate to clinical information that comes through with the claims.

Dr. Betty Rabinowitz:

So really what you're saying is by going through the adjudication process, the information that you can garner from those claims is much richer and broader than information you can gain by just analyzing your submitted charges basically.

Jamie Hayslip:

Yeah, that's a great point. It is broader and really offers a more holistic view of each patient's healthcare activity, because it represents services that happen, not just in a single practice or provider group. But it represents activity and services for that patient across a big spectrum of the services they may have no matter which provider they're going to. So it kind of provides that more holistic view of the patient's healthcare experience as well as the financial view.

Dr. Betty Rabinowitz:

So, in a certain way it's like taking a camera with a narrow lens and putting a very wide lens on it when you add claims into the mix. Because it tells you things, the patient costs that are incurred outside of your own organization. So obviously a very rich view in that regard. Often when we talk to groups about adjudicated claims, groups ask us where one gets those, how and where one gets those? How does a group go about even beginning to have access to these types of data?

Jamie Hayslip:

Well, it really comes through contractual agreements between the providers and the payers, and typically in the age of value-based care and incentives for cost reduction and quality that are part of what we call value-based reimbursement contracts. Typically there is a data sharing agreement in place that allows the providers to have access to those claims. That's true for the commercial insurance payer market. But if the provider groups are involved in government programs, like the popular one is the Medicare insured savings program, just being a participant of that program affords the provider group's access to the claims from CMS. So that's kind of comes along for the ride. It's kind of automatic as a participant of that program. But like I said, with the commercial agreements, commercial payer agreements, it's typically a specific de assuring clause or section of their contractual arrangements.

Dr. Betty Rabinowitz:

Absolutely. So sometimes groups ask us if we, as your group and team, Jamie, do we negotiate on behalf of the group with the payers? Or does the group do that as part of their negotiation?

Jamie Hayslip:

Yeah. It's really up to the provider groups to negotiate those deals. I think we certainly have some insights through our experiences. Well, some of our experiences before working at NextGen, some of us did work for payers as well as providers and were involved in those arrangements. So I think we have some insights that we can share and some tips that we can give. But ultimately is it up to the providers to negotiate those terms.

Dr. Betty Rabinowitz:

And once you have agreement that there will be data sharing and that the payers will make transparent to the group the true costs generated so that the group can begin gaining control over cost and utilization in a gain sharing or risk-based contract. We know that the devil is in the detail regarding that. What are some of the finer points of requirement and negotiation around the claim sharing that you have learned from your experience

Jamie Hayslip:

Yeah, so it's interesting. I think of my experiences with what we call in our team, there are claims implementation projects, which is really working with those claims and integrating them into our analytic system. But if I kind of go through the whole life cycle and the different phases of those projects, some things kind of pop out that really represent things that providers should consider as part of those agreements. I kind of break it down into like, okay, before we do an implementation kind of during, or what is the scope of that implementation project. And then afterwards, like when we're operational and we're exchanging data on a routine basis, what are some of the things to consider? So if you think about those three phases, like even before we get into an implementation project, we need to define, or the providers really need to come to an understanding of what is the population that it we're going to track, are going to be managed? That's kind of outside the nuts and bolts of data sharing, but it really has an effect on some of the nuances of data sharing. So let me give you an example. A population that is part of a contract can be defined in a couple of different ways. One way we call or describe it as like a locked in population. Or sometimes we call it prospective. And this is where we define a set number of patients or members of the population, and we don't change them over the course of like a performance year. So we kind of lock in and focus on that cohort through the performance year. Another way to do it is more of a concurrent method where maybe on a month-to-month basis, we update that population based on new members that have become eligible or come into the population and some that drop out of the population, and it's more fluid. But deciding which type of an approach you want for your managed population also has some bearing on, obviously, what data's going to be shared, when it's going to be shared, and so on. So that's one of the key things to consider even before implementation projects. The other thing is, you mentioned it already, like negotiate the true cost data and what we call like the paid amount data, which represents the negotiated amounts that the payers are going to actually pay the providers. That represents the true cost and gives us the ability to measure the cost of these programs. Sometimes that's not so easy. Sometimes the payers are reluctant to share that. But it's really important to kind of get that insight and have that information available. And the other thing beforehand is there may be an opportunity to ask for some data for the population even before are the terms of the contract are set. This allows the provider groups to kind of look at maybe the example population, see what the disease burden is in the population, like for example, how many diabetics are in the population. Maybe even use that data to see what quality measures or what level the quality measures are. And this can be done kind of before the contract is fully solidified. It really gives the providers kind of a level playing field as part of negotiation. I've seen this work to some success, and I've seen that some payer groups are definitely willing to share. It's probably like a de-identified data set, but it allows the providers to get a glimpse into the population even before the final terms are set. So that's some things kind of think about ahead of time. When we get into actual implementation project, we need to remember that not only do we need the claim data itself, but we also need member demographic and eligibility information. That's pretty important. We need to know if members or patients are eligible and enrolled in the program and what months they're enrolled. So that's a key component that we need to ask for. And then we need to think about the scope of the data that we're going to receive. Typically we like to have at least two years of data, claims data history, which really affords the ability to do some baseline, like maybe quality measure baselines, and also gives us some other analytic capability to see that history of data for that population. And that's a really important thing to think about for negotiating. And then once we've kind of gone through an implementation project and we have things more operational, we think of things like what are the timing of the data updates? Most times claims data is delivered on a monthly basis, but we should get a commitment from the payers on what day of the month that they're going to deliver that data consistently. So it's kind of like a service level agreement, right? Like we want to get it, expect to get it by a certain day of the month. And also we want a commitment for fixing issues. I mean, this is information technology and issues and bugs come up. So we want some kind of a service commitment by the payer to help work through those things as we go. And then finally, we talked about kind of this two years or claims history that we wanted initially. But if we are in a type of a managed population model where we're adding new members during the course of the year, we want what we call catch=up history. So if we add a new member, we'll want two years of history for that member as well so we can effectively look at the history and what has happened in the past for those new members. So if we think about the whole life cycle, these are all things that really should be thought of ahead of time and incorporated in these data sharing or contract agreements.

Dr. Betty Rabinowitz:

So let's assume a group, clearly a complex kind of early stage where it's really important to set the stage correctly and get attribution sorted out, and get the look back sorted out, and get the breadth of the data sorted out, and whether or not it will be paid amounts or allowed amounts where you want to get as close to paid amounts as you can convince the payer to provide you. You have all of this rich information. It goes into a population health analytics tool. What is some of the magic that happens with this data? What are the types of insights that a group can hope to have. Let's assume everything comes in perfectly and you've solved all these issues. What happens then? What's the good stuff?

Jamie Hayslip:

Yeah. Well, the good stuff, and what I like to emphasize too, is we need to remember that with this data, we get clinical insights as well as the financial and utilization insights. So I like remember that things like the diagnosis code information and the procedure code information, all that is really good clinical insight to, like I said, give a more holistic view of what's going on with a patient, where they're going for services, what they're being diagnosed with. That information is rich and can be added to things like our quality measure information to supplement maybe the clinical information we get from the clinical EHR systems, for example. So it does provide a good supplement to that, to give the more holistic and true view of things like quality measures and metrics. But certainly, now that we have the cost, we can do things like cost and utilization measurement, trending of that, of that information. And we can also break that down into different categories. So we can focus in on things like, oh, emergency department utilization and really see which patients are going to the emergency department, and maybe which ones are going for maybe avoidable or primary care treatable issues, and look for things to help steer people away from the ED. That's, that's one example. Readmissions is a great category to examine because we all know readmissions are very costly. So measuring the rate, the utilization rate of like things like readmissions, and putting in programs to address that are things that we can take action on. And certainly the cost. Starting to look at our costs, comparing that to our agreements with the payers, for these shared savings agreements. And doing things and putting into programs where we can see the cost, hopefully, go down are all very powerful. Then when we talk about, oh, things like provider performance management, now that we have cost utilization measures, we can combine those with some of the clinical quality measures to really get a balanced view of provider performance. We call that quality cost fusion in our system. It gives a nice, the whole balance of cost and quality, and allows us to assess the providers and the provider groups and how well they're doing on both fronts. And then even furthermore, there's some really powerful things like risk assessment, risk adjustment and risk assessment. So we can apply some tools to stratify the populations to see which patients are more risky in terms of high cost, high risk health, and other analytics like variations in practice patterns. So we can look at things like, oh, episodes of care, and we can compare one provider or one practice to another to see which may be working more efficiently and examine some of those good practice patterns and start to replicate them across our provider groups. So those are all some great things we can do with the data at hand.

Dr. Betty Rabinowitz:

Awesome. Awesome. So clearly a very broad and rich topic. Unfortunately, our time is ending. But if our listeners are interested in learning more about the use of claims in population health, feel free to reach out and learn more about the NextGen population health platform and claims analytics specifically. Jamie and his team will be happy to spend more time with you on any specific questions. If you enjoyed this podcast, you know what to do. Subscribe. We come back weekly with an interesting and different topic pertaining to healthcare. This is Dr. Betty Rabinowitz with NexGen Healthcare. Have a great day.