|
As part of carrier/health plan data cleansing
and preparation, CareAdvantage’s Data Analytics staff identifies
issues within two major organizational areas; source system
structural and data organization and ownership and business process
and policy deficits. As a more formal exercise, based on interviews with business
area owners and technical personnel, as well as supplemental
analysis of the data, a full Data Quality and Integrity Review can
be performed in order to identify areas of deficit and/or concern. The result is a report that provides observations and
actionable recommendations that will improve the overall management
of the health plan and its provider community.
Source System Structural/Data Organization
and Ownership
Source system structural and data
organization issues arise when based on limitations in reporting, it
becomes apparent that such systems have not been configured using
categorization schemes that are recognized in the industry as best
practice. Examples include:
- Compliance
shortfalls relative to HIPAA data format and values standards
- Sub-optimal
claim, membership, group and provider system configuration and
inter-relationship development
- Source
system non-ownership and championing
- Untimely
monitoring and updating of key standard data sets
The impact of source system, data organization and ownership deficits
include:>
- Moderate to severe limits placed on reporting flexibility
- Moderate to severe impacts on data validity and reliability
- Limited actionability and thwarted or incorrect decision-making
- Potential over, under or faulty claims payment where no liability exists
Business Process/Policy Deficits
Business process and policy deficits can be defined as those that do not take
into account and underestimate the impact of quality and integrity
controls over data acceptance/entry, processing and storage. Examples of such deficits include:
- Slack
code validity and timeliness acceptance tolerances with respect
to claims payment
- Provider
coding practice deficits and/or non-specificity
- Processor
claim adjudication and adjustments deficits
The impact of business process and policy deficits include:
- Flawed attribution of disease burden and resource consumption to
contributing plan populations adversely affecting current/future
risk and underwriting practices
- Limitations placed on achieving full NCQA accreditation
- Medicare and Medicaid under-assessment of disease burden and reimbursement
As a result of Data Quality and Integrity Reviews, our customers have
made changes in key processes as well as software that have enabled
them to measurably improve their systems and data that have resulted
in savings and/or retention and/or expansion of current business.
| 
