Tying It All Together:

Data, Process, and Technology to Support Optimal Medicare Reimbursement

Hospitals must navigate an incredible number of data sources to maximize their reimbursements from Medicare and Medicaid. This includes clinical and financial data from internal systems, as well as information from the Centers for Medicare and Medicaid Services (CMS).

In some cases, relevant data points are difficult for hospitals to acquire and validate. The challenge of ensuring payment integrity and optimizing cost reports is made all the more difficult because hospitals’ IT resources are facing complex regulations, rapid change, and multiple competing priorities. Below, we’ll examine how hospitals must coordinate data sources, business processes, and technology to optimize their Medicare reimbursement.

Healthcare Payment Specialists CEO Todd Doze explains the roles of data,
process, and technology in optimizing hospital reimbursements.

Accessing Disparate Data Sources

The data required to maximize Medicare and Medicaid reimbursement comes from multiple sources inside and outside of a hospital, including:

  • Clinical encounter data (inpatient and outpatient) from the hospital’s electronic medical records (EMR) system
  • Transactional financial data (stored separately from clinical data)
  • Information from Medicare and Medicaid databases
  • Other third-party entities, such as collection agencies, managed care organizations, and billing vendors

Collecting all the necessary data from these disparate sources is difficult. Particularly with regard to Medicare and Medicaid, it takes substantial administrative and technical knowledge to navigate the available databases effectively and obtain all of the pertinent information.

Business Processes and Technology

Once a hospital has collected the data, the process of matching EMR data to claims data from Medicare and Medicaid is still complex. The lack of unique, 1:1 identifiers makes it difficult to compare records and validate the data. However, this process is essential for hospitals to ensure they have fully identified their Medicare and Medicaid populations and are receiving the full reimbursement they’ve earned.

In the absence of a standardized process or technology solution, individual hospitals and health systems have developed algorithms or sets of queries that they run using off-the-shelf applications like Microsoft Excel or SQL. However, these methods may only capture 90% of the data matches—and missing that last 10% of cases can have a significant negative impact on total reimbursement.

Whatever solution your hospital uses, it’s essential to keep up with changing regulations. Each state has a specific set of codes that need to be understood and associated with the data in order to produce CMS-compliant analyses. Medicare, at the national level, has its own set of codes as well. These codes are often changed, removed, or updated to mean different things year by year.

CMS publishes approximately 1,500 pages of regulations every year—and the interpretation of these rules is not necessarily standardized across all Medicare Audit Contractors. It is complex and time-consuming for hospital finance groups to comb through this material and ensure compliance, which may mean they need to have dedicated staff or third-party legal counsel assigned to this task.

Thus, piecing the data together is not the only challenge. Once you’ve collected all of the relevant data, it’s essential to apply a thorough understanding of what that data means. It requires years of experience in healthcare payment integrity to ensure optimal reimbursement.

Tying it All Together with Healthcare Payment Specialists

When hospitals look to third-party vendors for assistance optimizing their reimbursement, these are two major concerns:

  1. The technology or services can be quite expensive
  2. Finding the best return on investment is often difficult

To deliver the most value from initiatives related to payment integrity, hospitals need a partner with a full understanding of all the disparate data sources, including experience connecting to Medicare databases. They must also possess the right tools and knowledge of business rules required by CMS to ensure that data sets can be matched and validated properly, in compliance with all applicable regulations and guidelines.

Healthcare Payment Specialists has developed a specialized platform offering extensive connectivity to Medicare and more than 45 state Medicaid agencies. We’ve also developed scripts that work with top EMR systems—facilitating data collection on both sides of the equation. For hospitals, our technology-driven process for collecting data reduces the cost associated with deliverables and speeds up the results, supporting optimal Medicare reimbursement and accurate cost reports.

Learn more about HPS’ differentiated technology and proven results.

Healthcare Payment Specialists

Healthcare Payment Specialists

Founded in 2002, Healthcare Payment Specialists (HPS) provides technology enabled solutions for health care eligibility, government reimbursement and compliance to hospitals and healthcare systems across the country. Using its STINGRAY software platform, HPS delivers solutions on a software-as-a-service (SaaS) basis or through outsourced service engagements.
Healthcare Payment Specialists