Claims data is created each time a patient covered by an active health insurance plan visits a healthcare provider. After the visit, the provider will submit a summary of services rendered to the patient’s payer for reimbursement, and that information forms part of the patient’s health record. Claims data is an important source of health information for providers and payers as it offers an overview of medications, diagnoses, procedures, and other key details about a patient’s medical history. That data can also be used to predict things like readmission risk and to inform preventive care strategies for high-risk patients.

However, when it comes to coordinating care during a health event like an emergency department visit or hospitalization, claims data alone is not a complete solution. The issue? It can take too long for claims to be processed for effective follow-up, and any mistakes on claims providers submit could lead to a denial.

For quality care coordination and better outcomes, adding a more agile solution to support claims data is ideal, so providers can reach out to patients during transitions in care when it has the greatest impact on health outcomes. During these care transitions, admission, discharge, transfer (ADT) alerts can fill the gap.

What is Claims Data?

Claims data is produced as part of revenue cycle management (RCM) for healthcare providers. RCM is the process by which a provider submits a medical claim to a payer to see what portion of the bill the patient’s insurance provider will cover and what balance must be paid by the patient. These medical claims consist of a summary of the patient’s health encounter using International Classification of Diseases in its 10th year (ICD-10) codes for diagnosis and treatment, as well as Current Procedural Technology (CPT) codes managed by the American Medical Association that identify what services were rendered (clinical lab testing, imaging, screenings, radiation treatments, immunizations, medications, physical therapy, etc.). The providers submit the claims to the payer and begin the process of collecting payment.

Claims data offers a summary of health encounters over time by showing diagnoses, treatments, and services rendered during a visit to a primary care provider, hospital, or other health facility using codes that are standardized across the health care industry. This claims data generated during the billing cycle in combination with clinical data stored in an electronic health record (EHR) can give providers a comprehensive overview of a patient’s medical history to support diagnosis and treatment planning.

The Limitations of Claims Data

Claims can be submitted by a provider and processed in as little as two weeks, but it can also take much longer. The RCM process is sometimes slow, and providers may not submit claims for payment until months after the health encounter has happened. Payers also have their own filing limits for healthcare providers that range anywhere from two months from the date of service to over a year. Moreover, if there are any errors or missing details in the claim, Medicaid officials have reported it can take up to a year to receive corrections.

While this variable timing for claims data processing may not be an issue in some situations, it can be an issue if a patient is admitted to the emergency department or discharged from the hospital. When there is a critical health status change, a patient’s care team needs to know in the moment, not two weeks after it has happened. To provide effective care coordination via patient outreach, the members of a patient’s care team need to be notified in real time when proactive interventions could support their health outcome and prevent a readmission.

In addition to the variability in the time it takes for claims data to be processed, there are several other limitations to relying on claims data to support patients during transitions in care. Although claims data is often touted for its longitudinal value, it can lack clinical detail and context necessary for effective care coordination. For example, claims data will not show the duration of symptoms a patient experienced before receiving a diagnosis, nor will it offer an understanding of patient outcomes after a diagnoses is made. There may also be conditions that do not have a unique billing code or providers may differ in how they select a code for the same condition, so the accuracy of the claims data could be affected.

Additionally, claims data does not provide information for uninsured patients, which makes up a large percentage of patients in some facilities like federally qualified health centers (FQHCs) or safety net hospitals that are designated for vulnerable populations.

How Admission, Discharge, Transfer (ADT) Feeds Can Support Claims Data

For providers to offer effective care coordination when a patient experiences a change in health status or is transitioning from one care setting to another, receiving a notification about the health encounter as it is happening is essential. Admission, discharge, transfer (ADT) data feeds offer care teams automated, real-time insight into what is happening with a patient to allow for timely care coordination and outreach. With ADT alerts, when a patient has a healthcare encounter like a hospitalization, discharge home, or a transfer from an inpatient to outpatient setting, their care team is notified and can take action.

The patient’s care team may include doctors, nurses, pharmacists, administrators, lab technicians, community health workers, therapists, and any other providers who play a role in that individual’s healthcare encounters. Various members of this care team will need to be notified when a patient experiences a health event, such as an emergency department visit, to ensure that the patient’s care plans, treatment goals, and medical history travel with the patient to the point of care. In addition, notifying the care team in real time gives them the opportunity to reach out to the patient when it matters—not weeks or months later. This can result in better care outcomes, reduced readmissions, and cost savings for providers and payers.

According to Beth Davidson, Director of HIE Implementation and Software Development at Audacious Inquiry, “It is critical to have claims data, along with ADT and other relevant clinical data, to help ensure the patient receives the right care, at the right time, in the right location. Ultimately, having a well-rounded collection of clinical and claim relevant details for the patient will produce better outcomes for the patient in addition to reducing duplicative services and lowering healthcare costs.”


Collecting ADT Data Feeds to Prevent Claims Denials

This support ADT feeds offer claims data also extends to authorization of claims by payers. Providers may benefit from keeping their own records of health encounters in addition to claims data to add a layer of added security in the event of a payer audit. Physicians, surgeons, and other treating providers should know payer-specific coverage requirements before they plan a course of treatment with a patient. Simply forgetting to check the right boxes or forgetting to log the use of an evidence-based decision-making tool in the treatment planning stage could lead to a denial.

This is where setting up payer-specific ADT alerts that are triggered, (for example, if a diagnostic code is missing from the claims record when a patient transitions from one care setting to another), could prevent the claim from being denied. It is more efficient to have providers review utilization in real time to adjust the claims being filed according to payer coverage requirements rather than having to appeal later because a detail was overlooked in the moment. It can save providers and payers time, money, and energy in the long run.

ADTs in Action: Example of ADT Impact on Care Coordination

To demonstrate the impact of ADT data in action, Primary Partners, an accountable care organization (ACO) in central Florida, began working with the Florida Health Information Exchange (HIE) Services to receive ADT notifications powered by Audacious Inquiry’s Encounter Notification Service® (ENS®). Before connecting with Florida HIE services to set up ADT alerts, most providers in the Primary Partners network only knew when a patient went to the hospital if the patient called the office and told them. As a result, patient outcomes were sometimes compromised, and they were paying unnecessary out-of-pocket expenses.

In the first year of receiving ADT alerts through the ENS service, Primary Partners saw a 40% drop in hospital readmissions among their patients per quarter, resulting in savings of nearly $284,000 in readmission costs. By receiving a notification when a patient was admitted or discharged from a hospital, Primary Partners’ providers could then schedule follow-up visits and plan proactive interventions to prevent rehospitalization for their patients.

“This is exactly why many of our HIE partners desire, and in some cases require, their data sources provide claims data, which is then combined with other clinical data and shared in ENS notifications to care teams,” explains Davidson, “HIEs see firsthand the value claims data provides for their participants and their ability to support transitions of care and care coordination for their beneficiaries by having a broader picture of the patient’s overall health status.”

Quality care coordination requires a fast solution that complements claims data by notifying providers when a patient’s health status changes in real time—not weeks or months after the fact. While claims data can offer vital information about a patient’s health history over the long-term, ADT data offers the possibility to notify a patient’s care team when they can offer support at a critical point in time. ADT alerts are agile for the type of outreach needed when a patient is admitted to a hospital, transferred, or discharged back home. During these time-sensitive transitions in care, patient outreach has the greatest impact.

If you are interested in setting up ADT alerts with Audacious Inquiry’s Encounter Notification Service, contact us to learn more.


About the Author

DIana Bauza About The AuthorDiana Bauza is a content writer based in the Greater Philadelphia area. She writes about products and services in the health and technology industries, with the goal of empowering consumers with quality information to help them make decisions that best serve their needs