Any organization that delves into the deeper use of analytics encounters a surprise, an “aha” moment that makes a profound impact in how it uses data for analysis. Hayes Management Consulting has compiled this list of eight such surprises, based on the experiences of its customers during their analytics journeys.
Few healthcare organizations have analytics you can get your hands on
Enterprisewide analytics often focus on expansive initiatives, such as population health, but there are other needs not being adequately met, according to Hayes. “We often see compliance leadership left hungering for analytics that helps them to focus on their key risk areas. The information you need exists, but it isn’t helpful if you can’t get your hands on it. Impediments include IT group bandwidth and lack of expertise with complicated analytics tools.”
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Analytics work even in areas you think you’ve got under control
One large organization had a rude surprise when the implemented risk-tracking analytics. Kwashiorkor, a form of malnutrition in children, has been a target for the HHS Office of Inspector General for several years. But Kwashiorkor is seen more often in developing regions of the world, and it’s rarely the proper code in the U.S.; overuse of the code drove up Medicare DRG reimbursement. The compliance officer instituted training on proper usage, but still found improper claims leaving the organization because of an interface issue with an external system. “Properly designed analytics should monitor a broad array of issues on an ongoing basis, including known problems as well as current and emerging risks,” according to Hayes.
Reports are not enough
Each quarter, CMS releases PEPPER reports highlighting metrics where hospitals are above the 80th percentile or under the 20th percentile for several key measures. A hospital with a high percentile could trigger a billing audit by CMS. A Hayes hospital client was above the 80th percentile for a cardiac-related DRG code and conducted analytics that found the providers driving that result were not the cardiologists. Drilling down into PEPPER analytics on the prior month’s data diagnosed the problem and enabled monitoring of mitigation efforts. “When compared to static reports on two-year-old data, there really is no comparison,” Hayes Management notes.
Look at things sideways
Some problems are tough to find via regular operational reports, but if you look at metrics from a different angle, you can get insights. Some customers needed help measuring critical care time. One indicator that critical care time may be overbilled is a provider billing an unusually large number of critical care hours in a 24-hour work day, which could flag the organization for a Medicare audit. Claim scrubbing and random audits won’t solve the problem, says Hayes Management. “However, by looking at your data organized by provider and service date and by applying estimated minutes to each billed code (per coding guidelines), you can quickly identify providers who may have risky or borderline billing patterns in this area.”
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Look outside your organization
“Looking internally at your own data is powerful, but you can develop tunnel vision. Broadening your data pool allows you to compare yourself to best practice institutions so you can set the bar appropriately to encourage continuous improvement,” says Hayes Management. Normative data from a cohort reasonably comparable to your organization helps target areas in which you are an outlier, so mitigation resources can be targeted to have the most impact.
You don’t have to boil the ocean
If you don’t have data scientists at your disposal, you are not alone, but you still can work on areas for which you have data and that pose the greatest risk to your organization. Start small, get comfortable with data and over time implement new focus areas.
Small data can yield big results
Start with what you know by making a list of current high risk areas. “If your organization conducts an annual risk assessment to prioritize audit focus for the upcoming year, start here and add to the list based on the OIG workplan, RAC focus areas and other recent judgments against other healthcare organizations,” according to Hayes Management. Inventory what data you have or can reasonably acquire, such as historical billing and remittance files. Medicare is increasingly providing data to the public, which can be a great source for national data.”
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Nothing beats expert insights: leverage your network
“Measuring what you know is important, but how can you keep up with what you don’t know?” Hayes Management asks. Where will you find the time? Leveraging your professional network can help. Reach out to peers in different parts of the country. “We find that small groups of seasoned compliance professionals working together can create magic.” Benefiting from the wisdom of others helps you better dive into data and weed out the insignificant.