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Integration between healthcare providers and hospitals is critical for the delivery of high-quality care and long-term management of costs. It's estimated that hospitals lose 10-30% or annual revenues due to patient leakage – no small amount. Thankfully, much of this loss can be prevented.

Healthcare marketing teams are vital support systems to any hospital or healthcare network’s operation, serving as consultants, brand representatives, relationship-owners, and drivers of business development. To best support their network, marketers must be equipped with the right information to guide their strategy – ideally, a blend of both quantitative and qualitative data.

That’s where claims data comes into the picture. Medical claims data is collected from all available healthcare sources for virtually all types of provided services – from specialty and preventative care, to office-based treatments and imaging. It can provide directional insights about specialty-specific referral behaviors, illuminate opportunities for increased loyalty, and point out key sources of out-of-network referrals. It can also bring forward warning signs of possible issues with providers, as well as new competitive market intel to get ahead of before it becomes more of a loss.

Despite all this, claims data is often under-utilized by marketing teams and their counterparts. This is perhaps due to its sheer magnitude, which can be intimidating when approached in raw form and extremely expensive to purchase directly. When targeted and analyzed thoroughly, however – with the assistance of a market and referral analytics solution – it can serve as a valuable resource for provider outreach. Under-utilization is also due, at times, to the challenge of learning how to interpret and trust the findings within the data – and knowing how to act on that intel.

In this blog post, we discuss several strategies for leveraging market claims data to support your provider outreach program and reach your goals in a smarter, more efficient manner. We also provide a brief overview on accessing claims data, understanding its limitations, and navigating the analysis process for maximum results.

Understanding market claims data

What is claims data?

Claims data encompasses all information made available by insurance payers about a patient-physician encounter, whether that encounter takes place in a hospital, emergency room, private practice, or other medical setting. In an ideal world, market claims data includes information on:

  • Provider activity
  • Diagnosis and procedure detail
  • Location or facility information
  • Patient demographics
  • Referral data
  • Payer detail
  • Net revenue

However, not all of this information is always available, and each claims data source has its own nuances that are important to fix or adjust. Specific details in claims data, such as the nature of services provided, are coded by payers for uniform organization and categorization. During the coding process, all patient data is de-identified for HIPAA compliance. The individual is then assigned a unique identifier for market research purposes.

Where are claims data sourced?

Claims data can be sourced from a variety of commercial and government-sponsored insurers. Claims data can also be pulled from EHRs, clearinghouses, and government agencies. On the pathway from the creation to eventual re-packaging and sale, a claim goes on a fairly convoluted journey – something that’s important to be aware of when considering the data’s accuracy.

After a provider renders care, the information must first be coded, after which the billing system will build and send the claim. The claim then flows through multiple routing “hubs,” arriving eventually at a clearinghouse. The claim is scrubbed, aggregated, and packaged for specific payers; the payer then adjudicates the claim and remits payment to the provider. Before reaching the payer, clearinghouses may also route data to be packaged for sale, removing any protected health information (PHI) in the process.

What are the limitations of claims data?

Inevitably, market claims data is never perfect. It tends to be highly fragmented: Different sources have different amounts of data available with varying levels of depth or accuracy, and data is available from these sources at varying frequencies. Furthermore, not all clearinghouses sell claims data to solution vendors, nor do all payers allow their data to be sold and accessed publicly. There is also variability within markets or certain geographies. The most reliable information (in terms of accuracy) within market claims data tends to be diagnosis and procedure detail, which is generally coded consistently, along with basic physician and referral information.

Leveraging claims data to improve outreach strategy

Before crafting a plan of action, it’s important to evaluate the quality of the claims data available. At a minimum, it should be robust enough to include healthcare provider demographics, PCP and specialist referring and attending physician detail, referring provider facility affiliations, outmigration and competitor volume, and both affiliated and out-of-network providers as defined by your market.

A solution like a healthcare CRM is the best tool with which to easily analyze claims data and set up, track, and report on outreach campaigns. This type of platform can be used to guide a drill-down on a specific line of service or to target individual practitioners – or some combination of both. It should also offer the capability to examine the data at the different affiliation levels and allow for interpretation of underlying data.

Start with questions

Once data has been accessed and interpreted, it’s helpful to start the planning process by asking some guiding questions. For instance:

  • Who is practicing in my market?
  • What kind of activity is happening across multiple service areas?
  • Who is referring to whom, and where are the referred patients being seen?
  • Are there any obvious provider-to-facility relationships?
  • Are there trends that are noteworthy and should be acted upon?

Once these questions are answered, it’s not difficult to pinpoint a specific list of providers and group practices to target. For instance, you might begin by identifying in-network providers who are frequently referring patients to out-of-network specialists – those “low hanging fruit” who can instigate a meaningful wave of change if they can be convinced to refer their patients in-network.

Or, if the goal is to increase referrals to a newly employed specialist, you might target independent primary care providers who are not currently referring to your network’s specialty line of service. Your healthcare CRM solution can help you refine and filter these lists down to manageable sizes for quick prioritization.

Set up a campaign

While claims data might provide your target list, the real work begins with how you choose to approach it. Use the CRM to set up each campaign. This way, you can easily track your interactions, measure your goal progress, and report on your results.

A robust, two-tier campaign strategy involves a high-level line of service campaign for each specialty in your network (orthopedics, bariatrics, neurology, etc.) as well as several more granular, physician-focused or referral-focused campaigns within each specialty. Knowing where you have a competitive edge – or where you may be first in market with an offering – is a great place to start.

Use multiple data points to research the providers on your target lists and find out which are most likely to be receptive to your outreach based on their history, in-network activity, and demographics. Then, revisit your data to determine patterns of referrals to employed, affiliated, independent and competitor providers. You’ll be able to differentiate ‘loyalists’ from ‘splitters’ and get a sense for what might be causing these patterns.

Finally, make sure to educate key stakeholders and hospital leadership about your efforts (using claims data as evidence). Check in frequently to ensure your outreach is in line with network-wide goals.

Cater to individual health consumers

During your research process, make an effort to extract information that will matter to the specific provider of focus. For example, let’s say you discover that one of your newly-acquired neurologists, “Doctor P,” recently conducted a groundbreaking clinical study on the use of new technologies to predict Alzheimer’s Disease.

Since you are responsible for onboarding Dr. P and developing his referral base, you decide to use his research as a targeting opportunity. You begin by pulling a list of in-network PCPs whose patients are primarily over the age of 65 – and therefore, statistically speaking, are more likely to see a higher number of Alzheimer’s-prone patients. You then narrow down this list by targeting the PCPs who are most frequently referring to out-of-network neurologists.

Summarizing and repackaging the findings from Dr. P’s study could prove to be a useful point of persuasion when speaking with target providers. If nothing else, it could spark a degree of curiosity. Back up your pitch by providing bio cards, offering invitations to community talks or grand rounds led by Dr. P, and, whenever possible, by conducting in-person introductions.

When it comes to building referrals, nothing beats a personal connection. If your new specialist has a gregarious personality, take advantage of it by setting up as many in-person interactions as possible. If this isn’t possible, use narrative to your advantage instead: Ask around for a compelling referral story or anecdote to share with providers during your visits (and then learn how to tailor it to the individual – not everyone is won over by heartwarming details). And, of course, always make sure to follow up with your referring providers to thank them.

Final thoughts

Personalization is key to long-term physician engagement. Without it, healthcare marketers will find that their efforts feel forced and robotic and will have very little impact on provider behavior. Additionally, a generic strategy can lead to lack of motivation and creativity for your counterparts. Using claims data, anecdotes, and other resources to personalize each interaction will set the stage for enduring relationships and lead to measurable results.