Healthcare IT Data Services – Case Study
Revenue, recovery, and process improvement for Ohio’s largest healthcare plan provider
Smart Data was enlisted by Ohio’s largest healthcare plan provider, to address issues with their nursing facility claims process. Initially tasked with updating the existing process to align with ODM’s retroactive code, our team discovered inconsistencies that were resulting in lost revenue for our client. Through a thorough analysis and technical solution, Smart Data was able to recover $16+ million in lost revenue and continue making improvements to the system. Read on to learn more about this successful case study of revenue recovery and process improvement.
16+ Million in lost revenue returned to the client
Initially, Smart Data was engaged to update the existing NFLOC processes to support a change by ODM(the “retroactive” code). While engaged in this process, our team noticed inconsistencies in the data that we believed the existing process was not handling correctly and that was likely resulting in lost revenue for our client. After further analysis, adjusting files were sent to the state resulting in lost revenue being returned to the client. Smart Data was then engaged to do an initial rewrite of the system in order to reduce the amount of revenue loss that was occurring within the existing process.
We developed a “deep data” analytics infrastructure that was used to mine claims data and identify any misclassified “in-patient” vs. “out-patient” cases and help recover enhanced compensation. The entire system was rebuilt as a .NET application with a front-end user interface for managing the process more effectively taking into account the issues with the data, the ability to correct rejected files, and auto-generate new files.
Identified the 100-day threshold date for members in the Nursing Facility (NF) Historical Report. For those who reached this threshold before MyCare became effective, the system aligned the threshold date with MyCare Ohio’s effective date. This allowed the state to recalculate the NF Level of Care (NFLOC)rate.
Ensured that members were eligible on the identified threshold date before including them in the report to the state. This made sure only eligible members were reported.
Produced a specialized file, known as the NF 100 file, and updated the audit log. This aided the state in calculating the NFLOC rate.
Excluded members who had taken more than 15 days of paid leave from the historical report. This action adhered to the maximum 15-day leave requirement.
Included members who had gone through specific admission and discharge patterns between NF and inpatient Hospital stays and had accumulated 100 or more days. This aligned with the 100-day requirement.
Consolidated data from historical NF 100 members and Facets NF 100 members into a single file. Duplicates were bypassed to ensure the state received only one report per day.
Smart Data delivered the new system on time and within budget. We were engaged multiple times afterward to continue improvements on the system after discovering additional flaws in misaligned data from other systems. In total, $ 16+ million in lost revenue was returned to the client.
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