Getting your game on with business data: a strategy for capturing and analyzing business data has the potential to reduce denied claims and increase revenue.

When providers file claims with payers, the rules of the game are "Two strikes and you're out." Hospitals and physicians have two opportunities to obtain full or partial payment: on "first pass," or initial submission, and afterward, when the payer returns a denied claim.

Until recently, providers found it difficult to improve their "batting average" and learn from their mistakes. The tremendous volume of paper and arcane details that constitute medical claims taxed the resources of many facilities and made categorization and analysis almost impossible. For example, the average medical group has more than 20 percent of its claims denied on first pass; half of these claims are never collected upon.

However, recent advances in claims format standardization have made it possible for a wide variety of healthcare organizations, including solo practitioners, to incorporate data warehouses and logic engines into their overall business data strategy. By creating data warehouses and employing analytical software, providers can have the same advantages as payers, which, with the benefit of mainframe computers, have long used these techniques to manage and deny claims.

Creating a Level Playing Field

The creation of a data warehouse, combined with its automated workflow environment, can virtually eliminate claims-related paper and fax transactions. Data are accessible electronically by departments throughout the organization, decreasing the need for staff to check on outstanding claims status requests or respond to third-party payers by phone or via the individual payer web sites.

Although certain claims management tasks will require individual attention, data warehouse technology has the capability to "thin slice" massive amounts of claims information into actionable reports, then route the reports to specific decision makers. These reports can identify issues by dollar volume or procedure code and suggest various actions.

The widespread adoption of standardized claims data--in particular, the X12N standards for electronic data interchange now required under the Health Insurance Portability and Accountability Act--can provide a blueprint for a common format for collecting, filing, and retrieving …