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Tying it All Together: Data, Process and Technology to Support Optimal Medicare Reimbursement

Hospitals seeking to maximize Medicare and Medicaid reimbursements travel a rough road. Navigating the plethora of data sources — including clinical and financial data from internal systems, and information from the Centers for Medicare and Medicaid Services (CMS) — can be daunting.

Many times, merely acquiring and validating relevant datapoints can be challenging for hospitals. And with IT resources facing complex regulations, rapid change and competing priorities, ensuring payment integrity and optimizing cost reports is all the more difficult.

We’ll examine how hospitals must coordinate data sources, business processes and technology to optimize Medicare reimbursements.

Accessing disparate data sources

The data required to maximize Medicare and Medicaid reimbursement comes from multiple sources inside and outside of a hospital, including:

  1. Clinical encounter data (inpatient and outpatient) from the hospital’s electronic medical records (EMR) system
  2. Transactional financial data
  3. Information from Medicare and Medicaid databases
  4. Data from other third-party entities, such as collection agencies, managed care organizations and billing vendors

There’s no question, it takes substantial administrative and technical knowledge to tap disparate sources and available databases to obtain pertinent information.

Business processes and technology

Once data is collected, validating and matching EMR data to claims data from Medicare and Medicaid is still complex — due to the lack of unique, 1:1 identifiers. Still, this process is essential for hospitals to ensure they’ve fully identified Medicare and Medicaid populations and are receiving the full reimbursement earned.

Many individual hospitals and health systems have developed algorithms or sets of queries to match data sources. Yet, these methods may only capture 90% of the data matches — and missing that last 10% of cases can significantly impact total reimbursements.

Whatever solution your hospital uses, keeping up with changing regulations is critical. Each state has a specific set of codes that needs to be understood and associated with the data in order to produce CMS-compliant analyses. At the national level, Medicare has its own set of codes which are often changed, removed or updated to mean different things year by year.

Thus, piecing data together isn’t the only challenge. It’s imperative you apply a thorough understanding of what that data means. This can require years of experience in healthcare payment integrity to guarantee optimal reimbursement.

Tying it all together

When hospitals look to third-party vendors to assist in optimizing their reimbursements, these are two major concerns:

  1. Finding the budget for potentially expensive technology or services
  2. Ensuring the best return on investment is achieved

To garner the most value from payment integrity initiatives, hospitals need a partner that fully understands disparate data sources, as well as one that has experience connecting to Medicare databases. They must also possess the right tools and knowledge of business rules required by CMS to ensure datasets can be matched and validated properly, in compliance with all applicable regulations and guidelines.

Learn more about TransUnion Healthcare’s differentiated technology and solutions.

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