Problem to Solve
While a regulatory framework in health care is essential for ensuring compliance with standards, the typical volume of regulatory reporting can quickly sap an organization’s productivity, increase costs and inhibit growth potential if not properly managed.
A large, integrated health plan needed to improve its internal data analytics and process workflows supporting the health plan’s regular filing of more than 100 federal and state regulatory reports. Due to significant growth in the volume and complexity of this health plan’s business, its leaders sought to optimize the quality and performance of the health plan’s data-related governance, structure, processes and usage.
A project of this scope, requiring significant and detailed research and analysis across multiple operational departments, and objective counsel, exceeded the health plan’s internal bandwidth and experience. The health plan engaged Freed Associates (Freed) to provide a comprehensive set of best-practice recommendations regarding the health plan’s data management, reporting and analytics. Freed’s prior experience with this particular health plan, and its past work with other enterprise-wide data management programs, provided the familiarity and expertise necessary to tackle this work.
Strategy and Tactics
Freed’s work was milestone-based, and sequentially covered three fundamental stages: research, analysis, and recommendations. Freed began by engaging the client’s project team to determine the project’s scope, deliverables and goals, as well as to create a project charter denoting accountabilities.
The research-gathering phase of this project entailed gathering input from more than five dozen of the client’s subject matter experts, on both the business and IT sides of the health plan, to determine current practices for regulatory reporting, handling and support. This work also involved mining and reviewing a wide variety of the client’s data tools, process flows and documentation, as well as determining all external and internal data sources and chains of report ownership.
As part of its analysis, Freed reviewed the client’s correspondence with federal and state agencies to determine the depth and degree of the health plan’s compliance accuracy. Special attention was paid to agency requests for report resubmissions and/or remediations in order to determine how, why and when reporting errors resulting in these requests were occurring.
Based on its extensive research and analysis, Freed generated data management recommendations for the health plan to begin using as a strategic roadmap for improving its future-state operations. This recommendations report included a systems design map for the client with end-to-end visualizations for an optimal future state infrastructure. It also included a recommended new operational infrastructure, covering such areas as enterprise data governance, an enterprise data warehouse and change controls.
Through Freed’s extensive research and analysis and set of best-practice recommendations, as well as recommendations for a new operational infrastructure, the health plan gained a comprehensive listing of its regulatory reporting, cross-referenced by ownership, responsibilities, data sources, and due dates. The health plan also has a roadmap for optimal data management handling, which includes ideal future state data and process flows.
Through these enhancements, the health plan has a much lower risk of being fined or sanctioned for missing filing deadlines, which could in turn delay program payments or payment rates and likely also impact membership counts. If any of these events were to occur, they would significantly and negatively impact the health plan’s bottom line.
Equipped with Freed’s recommendations, the health plan can now enhance its data handling and usage standards and optimize its reporting responsibilities, internally and externally. Once accomplished, the health plan’s new capabilities in advanced data analytics will help it more consistently achieve proactive and predictive process improvements, and enjoy a distinct financial benefit.