Authors
Healthcare litigation often involves the analysis of large and complex databases of medical claims data and clinical data. These databases can contain valuable information relevant to the legal theory of the case – from data elements one might expect such as volume of patients and cost of services, to less obvious but still potentially useful records such as the dates and times of patient appointments or the severity of the injury. RPC has the specialized software and the expertise to efficiently process and analyze these complex records. Our team has applied this capability for providers and payors in medical billing disputes, physician-hospital conflicts, and qui tam actions.
These data are often not stored in an easily accessible format, especially if a large volume of data needs to be analyzed. Hospitals and physician practices use different software for billing, appointments, and medical record keeping. Intentionally or not, the software vendors for these systems often make it difficult to extract the data. The information needed for a case may be effectively locked in an inaccessible format that cannot be accessed without expert help.
There are industry standards, particularly for claim formats, that facilitate rapid and accurate electronic data analysis given the right tools. The ANSI X12 837 Claim and 835 Claim Payment formats are standard data formats used to transmit billing and payment data between a provider, a clearinghouse, and a payor. The payor, clearinghouse, and provider are required to store these data for up to seven years. The billing and IT staff of payors and providers are often unable to analyze these data without expert help.
RPC has software to process ANSI X12 837 Claim and 835 Claim Payment data. We can also process data from provider billing software. Often, we combine these data with state and federal public use data files for further analysis. RPC’s Public Use Data Files include:
- Medicare Cost Reports for hospitals, nursing homes, hospices, and home health agencies
- Medicare Hospital MedPAR files
- Standard Analytical Files for hospitals, nursing homes, hospices, and home health agencies
- State public use data files for inpatient hospital stays and outpatient and emergency room visits
- State annual survey files
- Medicare provider data, National Provider Identifier (NPI) data, geographic data, and other reference files
RPC’s professional staff include certified coders, certified legal nurse consultants, data analysts, and economists who can analyze large data sets to identify false claims and improper claim payments and calculate damages in healthcare litigation.