Most people working in healthcare know that the cost for the same service can vary significantly by setting (e.g. office based vs hospital) and by provider within a setting. The example below illustrates this for a simple surgery with the price doubling in the Ambulatory Surgery Center (ASC) setting and being almost 5 times as … Site of Service Savings Opportunities
Analysts working with episode of care groupers for the first time often have questions about how to use the various value-added flags assigned to episodes. Episode of care groupers link together all of the claims that pertain to the treatment of a particular condition for a particular patient, to create a powerful unit of analysis. … Analytic Basics – Completeness and Outlier Episode Flags
This article was originally published in Employee Benefit News. It was written by both David Cusick and Brian Anderson. When seeking ways to keep expenses under control, health care plan sponsors may overlook the value of claims auditing. Auditing fees may not be inconsequential, but the fact is that an accurate audit including both pharmacy … Do Not Overlook the Value of Claims Auditing
Hospitals have historically relied on surgeries contributing to their top service lines and providing a significant source of revenue generation for hospitals and surgeons. This has, in part, led to the overutilization of surgeries. In the area of spinal surgeries, as noted in the Modern Healthcare article from March 24, 2014, the mounting research evidence … Too Many Spinal Surgeries?
Area differences in healthcare utilization have been documented since an area variation analysis of tonsillectomy rates was published back in 1938. Besides the research literature, geographic variation in U.S. healthcare also has been documented extensively for the Medicare population in the Dartmouth Atlas. The Institute of Medicine also released a series of reports on geographic … Regional Variation in Utilization – Syncope
One area of data management within the healthcare industry that is getting new emphasis and interest from regulators is a focus on encounter data. Today, the majority of Americans receiving healthcare services funded through the Medicaid program are enrolled in some form of managed care. Under this scheme, states contract with MCOs that take on … Tips for Ensuring Quality Encounter Data Submission in Medicaid Managed Care Programs
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