There is a massive amount of data contained within the U.S. healthcare system, on a scale that’s difficult to comprehend. In fact, the volume was estimated at roughly 150 exabytes of data in 2011, and will soon reach zettabyte and yottabyte levels.
The siloed nature of data management in today’s healthcare systems makes sharing this copious data between industry stakeholders a monumental challenge. Medical providers, insurance companies, oversight bodies, and government organizations need to make sure that their data is available to those who need it while making sure it’s handled securely and in compliance with HIPAA standards.
Thanks to provider management platforms, medical staff can instantly tap into these data sources on demand, and quickly retrieve information for credentialing, privileging, billing, patient records, and other administrative purposes. But what sources do they typically need to access on a regular basis?
Here are some of the critical types of third-party data medical staff will routinely access to deliver patient care.
Third Party Data Categories for Medical Staff
Patient records in electronic form, whether they’re EMR (individual physician records) or EHR (longer-term patient histories), usually live in different databases. Being able to find and access them can be a life-or-death proposition, and providers depend on the information they contain to deliver the best care possible.
Several data repositories exist which act as centralized healthcare data clearinghouses that are updated and maintained by various organizations within the healthcare industry. The Council for Affordable Quality Healthcare (CAQH) is a major data hub, and ProView platform is used by an estimated 1.4 million healthcare providers as a way to access a variety of critical information necessary for provider management.
Procedure and Diagnosis Codes
Procedure and diagnostic codes are a fundamental part of the healthcare system. CPT (Current Procedural Terminology) and ICD-10 (International Statistical Classification of Diseases) codes govern everything from determining and reporting on a diagnosis to prescribing and tracking the exact procedures used during treatment.
To ensure that physicians and medical staff are applying and using current medical codes, hospital administrators need to make sure that they are up to date. This involves receiving automatic updates through provider management platforms, or manually downloading them from the sources - the World Health Organization (WHO) for ICD and the American Medical Association for CPT - which can be a time-consuming process.
A large part of mitigating risk and ensuring patient safety comes from ensuring medical staff aren’t prohibited from practicing. While a provider may have their licensure and certifications in order, they may be on one of the many exclusion and sanctions lists which are maintained by various entities.
To make matters more complicated, this essential information is spread out among thousands of databases administered by government & professional organizations at both the federal and state levels. These include:
OIG Exclusions Databases
The Department of Health and Human Services Office of Inspector General (OIG) maintains the List of Excluded Individuals/Entities (LEIE), a database of individuals or organizations who are excluded from participating in federally funded healthcare programs including Medicare and Medicaid. All healthcare organizations who participate in federally funded programs must reference this list or risk significant financial penalties.
Exclusions are imposed for a variety of reasons, including:
- Medicare/Medicaid fraud
- Other healthcare felony fraud convictions
- Patient abuse or neglect
- Theft or other financial misconduct
- Unlawfully prescribing controlled substances
Other Federal Entities
Numerous other federal entities maintain their own sanctions lists, which must be verified in addition to the OIG database. For example, the U.S. Military Health System maintains a list of military-sanctioned providers.
State Exclusion Lists
Exclusion lists can also be found at the state levels. Not only do state medicare agencies publish sanctions and exclusion lists, but state medical boards may also maintain internal databases.
Typically, all of these lists would be checked in addition to the OIG exclusions list.
Insurance Companies/Third Party Payors
In addition to reporting on medical procedures and patient treatments to insurance companies for billing purposes, medical providers need to be enroll into each program. Provider payor enrollment is a laborious and time-consuming process, yet each medical practitioner must be pre-approved before the payor will approve billings.
Provider Management Software Handles Third Party Data Easily
Because of the vast amount of data sources that medical staff need to access on a daily basis - exclusion screening, billing codes, payor information and electronic patient records - it can be a monumental challenge to manage this information manually. Healthcare providers rely on provider management platforms to tap into all of these data sources automatically and quickly, offering a quick solution to the problems of too much data in the medical industry.