Hayes' Healthcare Blog

Defining Your Terms: Do You Have the “Analytics” Solution You Really Need?

Posted by Robert Freedman on November 16, 2016 at 9:00 AM

Big Data. Bandwidth. Paradigm. Analytics?MDAudit-Blog-4.png

It’s almost universally accepted that the first three have crossed over into buzzword territory and are in danger of losing any real meaning (if they haven’t already done so.) But is the term “analytics” heading down the same road?

We’re not saying analytics aren’t important. In fact, they are critical for healthcare organizations facing the onslaught of changes resulting from MACRA, increased oversight and the rush to value-based care.

But it’s important for us to define our terms. “Analytics” does not mean the same thing in all situations. In order to get maximum value, you need to make sure the analytics solution you’re using is appropriate for the task you are trying to accomplish. If it isn’t, you’re not likely to achieve your desired goals.

We spoke with one prospect recently who said, “Analytics is off the table. We already have so many analytics products. We don’t need any more.”

His situation may not be very different from your organization where you have no doubt deployed a number “analytics solutions.” You may have a large, expensive enterprise system in place. But if you’re like many organizations, those analytics programs are often focused on “bigger picture” issues like population health. While that is an extremely important initiative, as a compliance organization, you still need to leverage data for other operational goals like improving revenue flow and minimizing risk.

You may also have a number of system-specific analytics programs and visualization solutions that can provide valuable insight. Unfortunately, although these applications fall under the broad heading of “analytics,” they don’t provide answers that relate directly to your set of issues.

The end result is that even though your organization may possess powerful “analytics” solutions, you can often be left hungering for “analytics” that help you focus on your key risk areas. You may have trouble getting directly to the raw data you need but instead have to rely on filtered data provided by someone in an IT group. Such data sets compiled outside the compliance group can reflect a different purpose from the one you need. 

Actionable analytics requires iterative refinement of available data with subject matter experts who can pull out the “learnings” that are real and worthwhile. To accomplish that you certainly need “analytics,” but analytics that use raw billing and coding data to uncover risk areas before they can cause reputational and financial damage. These types of “analytics” solutions are much more specific. They are built on an analytics platform, but they are actually applications.

When looking for an analytics application best suited for risk and compliance management, here are five things you need.

Continuous monitoring of high-risk areas

Third party integrity regulators from the Office of Inspector General (OIG), Recovery Audit Contractors (RAC’s), Medicare Integrity Contractors (MIC’s), and Zone Program Integrity Contractors (ZPIC’s) have stepped up their game considerably. From fy2009 to fy2013 these programs resulted in over $5 billion returned to the Medicare Trust Fund. These entities are using more sophisticated monitoring tools to dig into your data to uncover payment problems.

You need the same tools to ferret out these issues before they do. You don’t want to be finding out after the fact that they’ve determined that you have gone outside of some range that they consider appropriate. For example, they can use PEPPER reports to compare you to your peers and if you’re above the 80th percentile or below the 20th percentile, you stand out as an outlier and are investigated further.

You want a solution that’s going to keep you one step ahead of these regulators and the key first step is continuous monitoring.

Efficient testing

Once you detect anomalies through continuous monitoring, you need to be able to dig into them to evaluate whether in fact they are a problem. If you are seeing something outside of the expected range of values, you need to determine the cause and then test to see if the issue is random or systemic.

For example, let’s say the accepted range of dispensing chemotherapy drugs is between 4 and 12 mg. However, your monitoring is showing instances where doses are being dispensed in the 1-2 mg range and others that are in the 13-15 mg range. You need to test to find out why this is happening.

By drilling into the data with an efficient testing tool, you find that the larger doses are for particularly obese patients while the lower doses are being given to patients who are being treated for macular degeneration of the eye. The issues showed up as anomalies, but through testing, it was discovered that they weren’t really problems.

To effectively get to the bottom of such issues requires analytics software with an automated workflow that enables in-depth and extensive testing.    

Actionable reporting

Identifying risk areas and testing to get to root causes are only the first steps in the process. You then have to implement corrective action to ensure the problems you uncover are eliminated. Accomplishing this requires effective reporting.

Without an analytics solution specifically tailored to billing and coding compliance, you may be left working in spreadsheets with no reporting capability. You are forced to type up summary letters describing the results in a way someone can act on them or to educate a provider on how then can get back into compliance with documentation and coding.

Reporting is a key element for value-based care programs and other initiatives heading your way. The Medicare Innovation Center is already producing a number of new ways of payment – all of which require meticulous documentation that require accurate, detailed reporting.

Targeted benchmarking

One of the key ways to uncover anomalies is by comparing your performance to your peers. Many “analytics” solutions will benchmark using information from CMS that is six to 18 months old and probably doesn’t represent your patient population. There may be thousands of two to three community physician practices that may have issues that are skewing the data to an imprecise model. You’ll end up comparing apples to oranges using outdated data.

The most effective analytics solution will allow you to make these comparisons easily and accurately to a population that best matches your own. You need ongoing, dynamic data from a peer group similar to your organization to compare your performance but to also find out what similar organizations are experiencing in areas like denied payments.

Ongoing development

Regardless of the analytics tool you select, it will have to continually evolve to meet the changing nature of the healthcare landscape. You want a solution that is based on intelligent development, constantly adapting using feedback from your peer organizations.

The applications should allow customization so you can monitor areas of interest to your specific organization. If you need to switch from monitoring three-day stays to two-day stays, you should be able to reconfigure your search criteria easily and quickly. You want easy access to your data to investigate and research potential problems that your testing has uncovered. You need to determine the scope, depth and range of the problem before you decide whether or not to test further and prioritize resource use based on potential impact.

Developing and updating this type of solution requires ongoing communications to gather feedback on best practices from dozens of compliance people from leading healthcare organizations across the country. This input then needs to be incorporated into further refining the application to ensure it stays relevant and effective for specific compliance monitoring purposes.

As you determine what you need to conduct efficient, productive monitoring of your coding and billing activity, be sure you are using the “right” analytics tool. That’s the best way to ensure you can identify and eliminate risks in your organization.

For more information, feel free to download our roadmap, 5 Ways Analytics Can Help Power a Risk-based Audit Program.


 Download Roadmap

Topics: Healthcare Analytics, Risk-based audits

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