How a Data Focus Feeds the Analytics Harmonization Engine for Medicaid Payer Plans

In a previous post, we explored "How Medicaid Payer Plans can hone their data focus," or in other words, become a data-driven organization. It’s the first step in building the right foundation to support nimble and effective adaptation to whatever Medicaid regulation changes come next. Like the name suggests, a data-driven approach places data at the center of decision-making, planning, and operational processes. Deploying it effectively creates an environment

where the organization’s central focal point is on collecting, storing, analyzing, and leveraging data.  It’s the critical building block Medicaid providers need for supporting the next phase.  

In this post, we explore how Medicaid payer plans can take the next step to build off that foundation to fuel what we’re calling the “Analytics Harmonization Engine” specifically for Medicaid Payer Plans. 

Challenges Medicaid Payers Face With Data Harmonization 

When you pull Medicaid membership data from one system, provider data from another system, and extract your claims-related data for reporting, Medicaid payer plans often face challenges in harmonizing this data to meet all regulatory requirements:

1. Communication Gaps Between Roles

Typically, a business subject matter expert with knowledge of the medical domain must collaborate closely with a data engineer to ensure that the extracted data complies with new requirements. However, there is often a communication gap between these two roles, which organizations frequently struggle to bridge on their own.

2. Data Fragmentation

Medicaid operates as a federal-state partnership, leading to significant variability in data collection and reporting across states. This fragmentation complicates efforts to create a unified dataset that can inform policy and practice effectively. 

3. Managing EDI File Types 

Each system, whether it’s lab results, member information, or service documentation, has its own unique data formats and standards. This complexity adds layers of intricacy to the data harmonization process, requiring sophisticated tools and meticulous attention to detail. Medicaid Payer Plans must handle various EDI (Electronic Data Interchange) file types for regulatory reporting, like EDI 835 for Health Care Claim Payment/Advice, and several others. Each file type has specific requirements and standards that must be met, adding to the complexity of data harmonization.

4. Technological Barriers

Implementing advanced data systems requires substantial investment in technology and infrastructure. Many states may lack the necessary resources or expertise to develop and maintain robust data harmonization systems. 

5. Interoperability Issues

Medicaid payers must work to ensure that their systems can communicate seamlessly with those of other payers and providers. 

6. Stakeholder Engagement

Payers need to ensure that the data collected reflects the needs and experiences of diverse populations, particularly marginalized groups. 

7. Resource Allocation

Limited funding and resources can hinder the ability of Medicaid payers to invest in data harmonization initiatives. Balancing budget constraints while pursuing innovative data solutions is a constant challenge. 

8. Data Quality and Completeness

Ensuring high-quality, complete data is vital for effective analysis and decision-making. Medicaid payers must address issues related to data accuracy, timeliness, and comprehensiveness to enhance the utility of their datasets 

Meet the Medicaid Analytics Harmonization Engine 

Bringing all these factors together is where an “Analytics Harmonization Engine” is both powerful and effective. 

Here are four areas where we can provide immediate results for Medicaid Payer plans with a Highly tuned Analytics Harmonization Engine:  

1. Data Ingestion and Reporting for Comprehensive Exams 

We excel at quickly understanding, ingesting, and reporting your data to ensure you receive full payments for services like comprehensive exams. A comprehensive exam involves measuring five systems, warranting five times the payment, provided it is documented. We can process the relevant data sets and generate reports to guarantee you receive all due payments for comprehensive exams. 

2. Mastering Medicaid Data Harmonization 

The complexity of harmonizing Medicaid data across different systems for regulatory reporting cannot be overstated. Each system, whether it’s lab results, member information, or service documentation, has its own unique data formats, standards, and protocols. This diversity adds layers of intricacy to the data harmonization process, requiring sophisticated tools and meticulous attention to detail to ensure that all data is accurately aligned and integrated. 

Accuracy and compliance are paramount in regulatory reporting. Accurate data harmonization directly impacts patient care by enabling healthcare providers to have a comprehensive and reliable view of patient information. This harmonization ensures that patients receive the appropriate care and that providers are properly reimbursed for the services rendered. 

We understand the critical importance of this process and have developed robust systems to manage and harmonize data effectively. By leveraging our expertise and advanced technologies, we can ensure that your data is compliant with regulatory requirements and optimized for accurate reporting and reimbursement outcomes without upcoding. 

 3. Wrangling Medicaid Regulatory Reporting 

Typically, a business subject matter expert with knowledge of the medical domain must collaborate closely with a data engineer to ensure that the extracted data complies with new requirements. What we find with many organizations is that there is often a communication gap between these two roles, which organizations frequently struggle to bridge on their own.  

However, we have had significant success in building solutions to address this issue for our clients. 

We have mastered creating extracts for regulatory reporting, ensuring compliance with state and federal requirements across the most common EDI file types: 

EDI File Type	Use
EDI 837	Health Care Claim or Encounter Information
EDI 835	Health Care Claim Payment/Advice
EDI 834	Benefit Enrollment and Maintenance
EDI 820	Payroll Deducted and Other Group Premium Payment for Insurance Products
EDI 270/271	Health Care Eligibility Benefit Inquiry and Response
EDI 276/277	Health Care Claim Status Request and Response
EDI 278	Health Care Services Review Information
EDI 999	Implementation Acknowledgment

4. Building Trust & Transparency - No “Black box” Solutions 

It’s all too common for healthcare solution providers to create "black box" systems. These are complex, opaque systems where the internal workings, methodologies, and processes are not transparent or easily understood by the users or stakeholders.  You can see the input and output, but what happens inside remains a mystery. 

When new personnel take over, they often struggle to get up to speed and understand how the system was built and how it operates. The lack of documentation and clear explanations means that the new team cannot easily pick up where the previous team left off, causing disruptions in service and potentially impacting patient care.  

"Black box" solutions hinder collaboration and continuous improvement. Without a clear understanding of the system's mechanics, stakeholders cannot effectively contribute to its development or suggest meaningful improvements. They are forced to trust the solution blindly, which can lead to frustration and a lack of engagement.  

This leads to steep learning curves, inefficiencies, mistakes, and ultimately, the endless burnout cycle continues. 

At OmniData, we ensure our solutions are anything but "black boxes." We meticulously document and demonstrate our developments to establish "trust through transparency." By collaborating closely with our clients on User Acceptance Testing (UAT), we ensure that your entire organization has full confidence in the Analytic Engine we provide. Our Future proof framework with comprehensive training means that even the most single-threaded organizations can ramp up and adjust to changing requirements easily, ending the burnout cycle for good. 

About OmniData: 

At OmniData, we specialize in transforming organizations into data-driven powerhouses. Our expertise lies in creating agile, scalable data ecosystems that align with your business goals and challenges.  

With extensive experience in data strategy, analytics, and modern platforms like Microsoft Fabric, we help healthcare clients design and implement data-focused solutions tailored to their unique needs. From streamlining operational processes to ensuring compliance with stringent healthcare regulations, OmniData partners with organizations to deliver actionable insights and measurable results.  

Still not sure where to start? Consider our complimentary workshops as a first step towards honing your data focus and becoming a data-focused organization. 

Our "Analytics in Action" workshops provide a comprehensive 1-day deep dive into your current environments. By the end of the session, you will walk away with actionable insights that can immediately impact your operations and strategy.  

Discover the power of data with OmniData and take the first step towards unlocking your organization's full potential. If you already have a strategy in mind and need a partner to help execute your Analytics Harmonization Engine, our Data Team as A Service may be a better option. Schedule a consultation to determine your best path forward. 

Get in touch and let us help you realize the full potential of your Medicaid data.