Accessing
Medicare claims
data within 2-4 days
I interviewed Medicare Engineers and Direct Contracting Entities that use Medicare claims data to coordinate care for their beneficiaries.
Team
Our team included a Program Manager, Project Manager, Technical Lead Developer, Two Senior Developers, Data Analyst, Subject Matter Expert, and a User Experience Researcher and Human Centered Design Lead
My Responsibilities
User Experience Researcher and Human Centered Design Lead
I created a storyline to connect the dots of the research, users, and their beneficiaries. I interviewed users to understand their pain points and would-be benefits to our solution. I also interviewed developers in Medicare to illustrate the problem and proposed solution.
Challenges
User access, client control of the experience with users, user's time constraints.
Solution
Creating a live data feed that users could access within 2-4 days as opposed to 25 - 30 days. This dramatic change will speed up care coordination for chronic condition patients.
Methodology
Researching data fields, raw data feeds within Medicare, users workflow, user's needs, and pain points.
Success Metrics
Our specific research allow us to create a pilot product that was useful to the ~130 users in a specific payment model of Medicare claims data. Medicare decided to go into production in May 2023.
Medicare healthcare providers need current data about their patients.
How might we give these users access to Medicare claims data sooner? What data fields do users need in order to succeed with their patient care?
Until recently, Medicare healthcare data was only accessible 3-4 weeks after a claim was submitted to Medicare.
Our team researched the benefits of accessing claims data early before it traveled through the Medicare adjudication process.
The benefits of accessing data quickly allows hospitals and clinics to
coordinate beneficiary care
expedite payments
track out-of-system care
improve clinical context
downstream payment cost savings
get ahead of claim rejections
track financial performance
Our research, analytics, and engineering ingenuity changed this.
Our users were Accountable Care Organizations (ACOs) from a variety of payment models within Medicare. We demonstrated to Medicare that access to claims could greatly improved care coordination and outcomes.
Our team created an enhancement to an existing Application Programming Interface (API) platform.
We answered these questions:
What system do we use to give users access to claims data?
What data fields do users need to make timely analysis about their customers?
Research Goal #1
PART 1 - Interviewing Medicare developers and investigating system analytics to map out the claims flow in Medicare.
Within Medicare, what information flows where?
What systems processes which data?
How is our team changing this?
Where does claims data originate?
What system is best to capture this data?
After interviewing several Medicare developers, I created the claims flow diagram below to illustrate the new pathway of data our team created. Medicare did not have a diagram of claims flow so this served a dual purpose.
PART 2 - Claims Phases Diagram
My colleague gave me an Excel file illustrating specific data that was populated in each Phases of the Claims Adjudication Process. I created a visual to explain it. This helped Medicare stakeholders understand what happened in each phase of the data and what user would see with early access to this data.
Research Goal #2
What data fields do our Accountable Care Organizations need?
What case studies are most vital to their business objectives?
Through one-on-one interviews, context research and surveys, our team was able to identify specific fields to include in the data feed. The accountable care organizations use patient data to notify their healthcare providers when a Medicare patient has an urgent healthcare need.
Users were studied and interviewed in context.
Their behaviors and motives were investigated.
By inference, interpretation, analysis, and synthesis I made sense of this data. In the end, I gained powerful insights that demonstrated to Medicare the importance for users to receiving timely data. The data also pointed Medicare towards several additional services they could provide.
User Engagement
We created surveys and monthly Webinars to engage users with each other and introduce pertinent topics. These engagement projects were also necessary to understand the data fields different users were using and why.
Onboarding Users to the Pilot
I suggested that we create documentation for users to onboard the pilot. I gathered all of the information necessary to understand the data, the context, and onboarding.
Participation Guide
I also created a Participation Guide to guide users into this new data enhancement and show them what data way offered and how to access it.
View the Participation Guide.
Use Case Illustrations
I created various illustrations for use case dashboards. This is one example.
Dashboard Prototypes
These prototype dashboards I created not only to illustrate a use case, but to use to test with users to eventually create a standard dashboard.
At the end of our pilot, I interviewed users.
Below are a list of questions I asked.
General Performance
What did you do with the data? Were you able to work it into your workflow? Do you have projections to do so? How did you analyze the data during the limited launch? How often do you access PACA? Why is this effective?Between all 3 FHIR® resource types for fully adjudicated claims: Explanation of Benefit, Patient, andCoverage, which one(s) is the most useful in conjunction with partially adjudicated data? Have you found any specific use cases for the data in your claims process? What use case is your focus? Which are your top five data requests? What information do you want to know about an encounter with a beneficiary that you're not getting now? Give us an example of one of your hypotheses. What are currently measuring? How could having data earlier help you with your quality metrics?
Data Fields
What data fields were most valuable to you and why?We've learned from you that EOB, Patient, and Coverage data would be useful to get sooner. Is that correct?All of those fields cannot be imported from EOB, Patient, or Coverage. If you were to choose 10 fields in EOB, what would they be?[Open up the data dictionary and talk through the potentially available fields. Present a table of data or categories that we could make available. Ask them if they need it and then check that box. What here would be valuable to you? Which fields do not necessarily need to be accessed early?]Looking at Patient and Coverage, which fields do you focus on? Would you benefit from receiving this earlier?Are there any fields that you need for your processes that are missing?How is partially adjudicated data integrated with other sources?
Quantify Patient Outcome
How many of the patients that you manage are covered by FFS Medicare? Have you had enough time to see a change in readmission rates by using partially adjudicated data? Is it possible to quantify the value of early data for providers? What will be the benefit of the data you obtained for patients? If we interview a Utilization Manager: Can a better connection to patient data help providers? What will be the benefit of the data you obtained for patients? When closely followed, how many patients stayed within the network? Is it possible to quantify the benefits of having inpatient information sooner? What role does data play in care management? Small DCE Challenges and General Risks How does a small DCE's workflow differ from that of a large DCE? What challenges do small DCE companies face? How could Medicare help?Will this year's annual break in data availability affect the value?
Email Me
jennymikesell AT gmail