Claims Data Frequently Asked Questions

Claims Data FAQs | Healthcare Data Analytics

Over the last decade, healthcare teams have been actively working to identify where their marketing, business development and outreach resources can make the most impact. Some of the data sources they’ve used include internal encounters, inbound and outbound referrals, state and CMS data. Many are also investing in all payer claims data to optimize their service line planning.

If you haven’t used this type of data in the past, you probably have some questions. Here are some of the most frequently asked questions we receive.

What is all payer claims data?

A collection of hospital-based and ambulatory claims procured by a variety of 3rd-party medical and pharmaceutical billing systems, payers and clearinghouses.

How do business development teams benefit from claims data?

Ambulatory data can be used to better understand which providers are performing targeted procedures today–both inside your organization and for competing organizations. Knowing this can help you understand which current providers to partner with, as well as top providers who may be poised to align with your organization going forward.

Ambulatory data is also great for exploring shared patient connections and evaluating which referring providers should be targeted for retention, recovery, nurture or growth.

How closely will all payer claims data match my internal data trends?

Because our healthcare system includes multiple payers, electronic health records (EHRs) and billing systems, no data vendor can offer 100% claims capture. Meaning data will never be a complete or accurate match to your internal trends.

On average, our clients see approximately 70% capture–depending on their market size and the billing systems used by targeted providers. This is why we recommend our clients use claims data as a supplement to understand key market trends and potential provider connections.

How often should my team expect to see new data?

Processing claims quickly is paramount for clearinghouses. For this reason, ambulatory claims are pushed to them on a daily and/or weekly basis. Our clients then receive quarterly updates. So, at the time of import, their aggregated data represents the most current 12 months of data available, with the oldest claims being approximately 2-3 months old.

What limitations should we be aware of before purchasing claims data?

Because data is typically aggregated at the NPI level, all payer claims data can lack views into non-NPI driven service lines, like outpatient rehab, home health and hospice. Also, HIPAA regulations often limit what fields clearinghouses can share with claims vendors. Which means the information that your organization might rely on for patient market share analysis may be limited or unavailable. Do your due diligence.

What should I look for in a business intelligence partner to help visualize data?

One of the primary reasons people pause when it comes to using all payer claims data is cost. However, my clients find that investing in ambulatory data creates returns that can outweigh these costs because accessing a wider variety of sources, payers and places of care offers a more complete view of opportunities in their markets.

That said, it can be labor intensive to gather and analyze external data in a way that leads to action. This is why many use a business intelligence system that can automatically organize and visualize the insights needed to grow key service lines and provider relationships.

Our data analytics platform, for example, has user-friendly dashboards that allow different team members to easily filter and sort claims (and PRM) data to quickly identify top providers by service line, procedural group, specialty, market, payer, growth initiatives and more.

What about leakage? Can I see this within all payer claims data?

Yes. While providers may share patients with multiple providers in your market, the percentage of total eligible patients shared can suggest the strength of existing referral relationships.

For example, we work with clients to identify which providers and facilities are considered in-network, network friendly, targeted competitors and/or out-of-network. Then assign each group a color in our BI dashboards — which helps our clients quickly visualize which relationships to reinforce or redirect.

You can also visualize trends between network groups by defining the major health entities within your market, and then assigning the appropriate providers and facilities to these groups.

More Questions

Do you have additional questions on how to use data to guide your physician outreach? Please email me at Before being Marketware’s Vice President, I was a Marketware customer myself! So, I know, firsthand, the impact data can make to a business development program.

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Date: October 27 2021
Subject: Healthcare Analytics
About the author
Josh Cameron, MBA — President, Marketware
Josh Cameron, MBA

Executive Vice President

Marketware, a Division of Medsphere