Using claims data insights to improve healthcare provider outreach

Editor's Note: This is the third and final of a three-part series offering insights into the fundamentals that drive growth for healthcare organizations. 

Medical claims data is collected from all available healthcare sources for many types of provided services. It could run the gamut from specialty and preventative care, to office-based treatments and imaging. This data offers valuable insights into specialty-specific referral patterns, highlights opportunities to strengthen provider loyalty, and reveals key sources of out-of-network referrals. It can also uncover early warning signs of potential provider issues and surface competitive activity — giving you a chance to act before it impacts your market share.

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 the expense of purchasing directly. Underutilization can also stem from the difficulty of interpreting data, knowing how much to trust it, and understanding how to act on the insights. But when the data is carefully analyzed and targeted — with support from a market and referral analytics solution — it becomes a powerful tool for guiding provider outreach.

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

Interpreting market claims data

Claims data encompasses all information made available by insurance payers about a patient-physician encounter. This is true whether that encounter takes place in a hospital, emergency room, private practice, or other medical setting. In an ideal world, market claims data should include 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 data sources tend to have their 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.

Claims data can come from a range of sources — including commercial and government-sponsored insurers, EHRs, clearinghouses, and government agencies. But it’s important to understand that each claim often goes through a complex process before it’s ultimately packaged and sold. That journey can affect the accuracy and consistency of the data, so it’s essential to keep that in mind when using it for analysis.

After a provider delivers care, the visit details are coded and entered into a billing system, which generates and sends the claim. From there, the claim passes through several routing hubs and eventually reaches a clearinghouse. At this stage, the claim is scrubbed, aggregated, and prepared for submission to the appropriate payer, who then adjudicates the claim and sends payment back to the provider. Along the way, clearinghouses may also route de-identified data for resale, ensuring any protected health information (PHI) is removed in the process.

Inevitably, market claims data is never perfect. It tends to be highly fragmented. Different data sources offer varying levels of detail, accuracy, and availability. In addition, data from these sources is released at different intervals. Not all clearinghouses sell claims data to third-party vendors, and not all payers permit their data to be publicly accessed or sold. 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. It is generally coded consistently, as is 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 drill down on a specific line of service or to target individual practitioners (or some combination of both). It also offers the capability to examine the data at the different affiliation levels, and allow for interpretation of underlying data.

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 provide 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.

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 can be the first in your 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.

Align strategy with stakeholders

After uncovering the best next action via advanced data analysis, it’s time to communicate the findings to key stakeholders. Make sure they understand exactly how these insights translate into growth opportunities, and ultimately of course, the dollar value behind it all. Unlike a vanilla CRM system, a comprehensive insights solution shouldn’t just portray data in list form. Instead, it should provide concrete analytics that can easily be visualized and understood by multiple stakeholders in the boardroom.

This is a refreshing alternative to the subjectivity and conjecture that have ruled health system boardrooms in the past. With a visual, data-driven approach to data sharing, your organization will not fall victim to the misinformed or under-informed marketing decisions that plague many modern health systems. The insights will also help align initiatives with the goals of stakeholders across departments, since the platform integrates data from so many different sources. 

By centralizing data and delivering a visualized, data-driven analysis, your health system can align on objective facts rather than subjective opinions (that tend to lead campaigns astray). From there, the key is to regularly monitor progress to ensure outreach efforts remain aligned with network-wide goals.

Final thought

Personalization is key to sustained physician engagement. A one-size-fits-all approach risks feeling impersonal and ineffective. Additionally, a generic strategy can lead to lack of motivation and creativity. By leveraging claims data and real-world anecdotes, organizations can foster meaningful connections, drive provider engagement, and achieve measurable results.

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