Financial Impacts of Unscrubbed Data

June 18, 2015
|In Performance Optimization, Brain Food
|By GHG Advisors

We have written many articles on the importance of maintaining accurate, reliable data. Data is everywhere and in many versions. Health plans need to be very careful to input only that information coming from a reliable source of truth. In government programs, that reliable source of truth is prescribed to be information contained within the government’s systems. “Scrubbing” data means reconciling against that reliable source of truth. For health plans, this means reconciling with information within the government’s systems, regardless of whether that information is right or wrong. Correcting the government’s erroneous information requires adherence to prescribed processes.

The most effective way to process transactions with government programs is using the government’s own data. This is most effective because it greatly lends itself to automation. A clear example of how this works is in Enrollment processing using what we call an “Intelligent Front-End.” The objective of an Intelligent Front-End is to import the government’s data and then utilize that same data in transactions back to the government. This Intelligent Front-End also receives data files from the government and then utilizes that same data to trigger required actions within the health plans’ systems. This tactic ensures reconciliation, compliance, efficiency, and manageability.

Another example of utilizing “scrubbed” data is in validating health care providers’ information. This is critical for provider credentialing, contracting, medical claims processing, pharmacy claims processing, risk adjustment, and encounter data submissions. The monthly National Plan and Provider Enumeration System (NPPES) National Provider Identifier (NPI) downloadable files and weekly incremental NPI files provide an abundance of information. Combining the Medicare Exclusion Database (MED) and Office of Inspector General List of Excluded Individuals and Entities (LEIE) helps to build a national universe of health care providers’ information. Automating reconciliation with this comprehensive database can tremendously expedite provider set-up for processing claims from non-contracted providers. This helps to avoid interest payments for untimely processed claims.

It is imperative for health plans to keep current on updates to payment codes. This includes:

  • International Classification of Diseases, Ninth Edition, Clinical Modification (ICD-9-CM);
  • International Classification of Diseases, Tenth Edition, Clinical Modification (ICD-10-CM);
  • International Classification of Diseases, Tenth Edition, Procedure Coding System (ICD-10-PCS);
  • Current Procedural Terminology (CPT);
  • Healthcare Common Procedure Coding System (HCPCS);
  • Modifiers;
  • Revenue Codes;
  • Place of Service;
  • Bill Types;
  • Condition Codes;
  • Occurrence Codes;
  • National Drug Codes (NDCs).

Finally, it is absolutely necessary for health plans to keep current on updates to fee schedules and prospective payment pricers. Provider payment disputes are on the rise. Ironically, so are overpayments to providers. Ensure payment accuracy by utilizing up-to-date fee schedules and pricers.


Resources

Gorman Health Group (GHG) includes some of our industries most experienced and proficient health plan subject matter experts. Our consultants can help your organization with developing or improving your Intelligent Front-End, scrubbed health care provider information and national provider database, and assess whether your claims adjudication codes and payment systems are current and used appropriately. Contact us today to get started. >>

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