How Nebraska Medicine Turns Claims Data into Revenue Cycle Strategy

September 15, 2021 - Healthcare providers and payers send millions of business transactions a day. These transactions ensure providers get paid for delivering care to patients, but they also create a treasure trove of data points.

Claims data paint the picture of the administrative process taking place behind each clinical encounter. The information includes billing codes providers submit to payers to indicate a reimbursement rate for a given encounter. However, this information can also fill in the details around care delivery, healthcare operations, and revenue cycle management.

At Nebraska Medicine, for example, claims data has created a view into internal processes and even how the health system functioned during the COVID-19 pandemic with the help of an analytics tool.

“During the March and April timeframe last year, when a lot of facilities were stopping elective services and volumes were down, we really had an opportunity to use that data to anticipate where we were going moving forward,” Jana Danielson, vice president of revenue cycle at Nebraska Medicine, recently told RevCycleIntelligence.

The revenue cycle team at Nebraska Medicine also leveraged claims data to manage new telehealth capabilities.

READ MORE: Medicare Claims Data Show Health Disparities in COVID-19 Patients

“As telehealth grew, the claims data was helpful for assessing if we were effectively managing all the different payer requirements,” Danielson explained. “For example, one payer wanted a 95 modifier, and another wanted a GT. Claims data helped us pivot quickly by identifying issues and allowing us to stay on top of it to make sure services were being processed appropriately, and not just for financials—getting paid for what we were doing—but also for the patient, making sure they knew their out-of-pocket expense, that was accurate, and that we got it to them in a timely fashion.”

The analytics tool was and continues to be key to synthesizing the massive amount of data generated by the also massive number of claims going in and out Nebraska Medicine’s doors each day. And for Danielson, that tool has also been paramount to turning claims data into revenue cycle management strategy.

Transforming claims data using analytics

Nebraska Medicine has been using a claims analytics tool for several years now as part of the health system’s relationship with The SSI Group.

“It organizes our claims data in a way that provides us information that's valuable to look at to see if there are internal process changes that are necessary or if we have payer issues that we need to address,” Danielson explained. “It is really a comprehensive view of claims that are going out and the information that's coming back in, so we can see if there are hiccups or gaps along the way, either on our side from a provider perspective or from the payer side.”

Armed with the information, Danielson has created strategies around the identified “hiccups or gaps,” which the revenue cycle leader also described as opportunities for improvement. For example, Nebraska Medicine used to receive data back from payers that created denial records for remit codes indicating services not covered. Danielson’s team knew the services were not covered but had sent the claims out because they wanted the payer to process them as contractual per the system’s payer contracts.

READ MORE: RCCH Uses Predictive Analytics to Boost Claim Denials Management

“Seeing all of those come in through the tool, we were able to change our internal workflows, so we were not having to look at those claims twice,” Danielson stated. “We also changed the way in which we were able to take some auto-adjustments, knowing that was how the payer was going to send those back.”

On the payer side, the claims analytics tool has helped the revenue cycle team at Nebraska Medicine improve claims management workflows with their payer partners. For instance, the claims data showed that one payer took longer than their peers to pay the health system.

“It opened up the door with the payer to talk about how long they were actually holding things before they processed them for payment because in their mind they were auto-adjudicating and paying on a weekly check run,” Danielson said. “In reality, they were holding things for 14 to 21 days before they would run them through for payment.”

Using the analytics tool, the revenue cycle team was able to deliver data-driven feedback to open the conversation with the payer and resolve payment delays.

“That's not to say that the communication or the conversation is always how we would like it to be, but I think that if you go in with actual data and information to start the conversation, it helps,” Danielson added.

READ MORE: 3 Strategies for Revenue Cycle Management Optimization

Overall, using analytics to identify opportunities for improvement and acting on them has contributed to one of Danielson’s major goals for Nebraska Medicine: getting claims as clean as they can be before heading out the door to payers.

“We have the ability to really look and see who our top payers are, where they are having issues, and what we can do upfront to help,” Danielson stated. “The tool gives us great insight into how that’s all functioning.”

“It’s also extremely helpful from a time perspective. Resources are tight and there is a lot of stuff on people's plates, so the easier that we can make things or the more efficient, the better off we're going to be.”

Executing a revenue cycle management success strategy

Analyzing claims data is central to Nebraska Medicine’s revenue cycle management success. But Danielson also attributed the health system’s successful strategy to transparency.

“Having an open dialogue and having everyone working together to come to an agreement on the best solution is extremely important,” Danielson advised other revenue cycle leaders. Nebraska Medicine’s revenue cycle team, for example, has daily calls to discuss emerging trends from the claims data.

Success also hinges on tracking and monitoring improvements. “We have a tracking method in place to confirm that the long-term outcomes stay within the realm of where we want them to be and then we move to the next thing,” Danielson explained.

The latter point is just as important, Danielson emphasized. Revenue cycle teams should not try to boil the ocean. Claims data and analytics will likely reveal several internal and external opportunities for revenue cycle management improvement and it may be tempting to implement a data-driven strategy to tackle them all.

However, Danielson advises leaders to take it one issue at a time. “Sometimes we try to tackle way too many things, but without the focus, you won’t get something completely done.”