CMS continues to push for higher quality of healthcare data, and they have recently drafted regulations that call for data quality standards which they will enforce throughout the healthcare industry.  In the draft regulations CMS calls for complete datasets, which include beneficiary and provider information; all service related data including procedure and diagnosis codes; and all payment amounts with dates.  The draft rules also call for the use of industry standard Accredited Standards Committee (ASC) X12N 835, ASC X12N 837 transactions; National Council for Prescription Drug Programs (NCPDP) transactions; and data ‘timeliness, accuracy, and completeness.’  CMS plans to make the data quality measures a contractual obligation for any entity that participates in any Medicare/Medicaid program, and they have even threatened to defer money to entities that do not meet the draft data quality regulations.

Effective January 1, 2015 the California Department of Health Care Services (DHCS) has implemented mandatory Quality Measures for Encounter Data (QMED) for healthcare data submitted by managed care plans (MCP) that specifically calls for data completeness, accuracy, reasonability, and timeliness.  DHCS will grade MCP performance and issue quarterly scores based on published QMED standards. Starting in 2016, DHCS will begin enforcing sanctions against non-compliant MCPs.  The QMED standards are expected to change annually as a means to continually improve the quality of healthcare data.

FennecTM measures and analyzes healthcare data; it is a business rule driven data quality enforcement tool dedicated to applying rigorous rules on datasets.  It enforces and provides insight into the completeness, meaningfulness, accuracy, and timeliness of healthcare data as outlined by CMS, CA DHCS, the Affordable Care Act, and other data quality organizations.  FennecTM enforces the requirements defined by the Health Insurance Portability and Accountability Act (HIPAA) ASC X12 837P, 837I, 837D implementation guides, and the 2.2 and 4.2 NCPDP payer sheets, which are healthcare transaction dataset definitions mandated for use in the healthcare industry.  The following list outlines some of the data quality measures that FennecTM enforces:

  • Data Completeness – percentage of duplicates, trend reports
  • Data Meaningfulness and Accuracy– turnaround time, procedure per visit, procedure codes and modifiers, diagnosis codes, revenue codes, void and replacements, provider details (billing, rendering, referring, prescribing, etc.)
  • Data Timelines – lag time, lag time averages
  • HIPAA X12 and NCPDP standards

Since FennecTM is a business rule driven quality enforcement tool, it is easy to add other data quality rules to existing datasets.  Data quality rules can be applied to individual Trading Partners, lines of business, or any identifiable data entity – FennecTM is truly that flexible.

As it stands FennecTM Data Quality Control is software as a service solution and requires very little configuration to integrate with any healthcare data processing workflow.  FennecTM comes with a recommended workflow that is intended to facilitate the way Trading Partners exchange healthcare data.  FennecTM enforces data quality edits as data is received from Trading Partners in real-time.  The intent is to address data quality prior to data entering into any system by applying the rules then transforming the data into a standard canonical dataset that is dependable and measurable (note: native transactions can also be passed after data quality rules have been applied).