Putting Data to Good Use: How Inovalon Makes Meaningful Data Accessible

Michael Quinn, Former Vice President of Strategic Partnerships at Inovalon, said that the data to help provider organizations determine coverage – and to help them ensure that they receive every claim reimbursement owed to them – is already out there.

“Inovalon was created to help healthcare organizations, especially those with very little technology enablement, connect with their largest payer, Medicare,” explained Quinn. “Today, nearly all Medicare claims route through the Inovalon before they get to CMS. This network processes a huge amount of data and claims information. As a trusted data insights organization, Inovalon recognized that this database could provide value to the industry in other ways. That’s why we’ve evolved into a commercial clearinghouse that connects providers to payers not only to help solve revenue cycle problems, but also to help providers deliver better care to patients.”

Invicta Health Solutions helps its provider partners develop solutions to “streamline the basic blocking and tackling” required in the revenue cycle management space. Because of that expertise, Invicta understood that having a primary connection to Medicare was essential for helping providers determine coverage for patients so they could bill HRSA as needed.

“Working with Inovalon, we could develop something that could do a kind of insurance discovery for CMS coverage on patients,” Shaw said. “That meant providers could better ensure they were getting payments from CMS or HRSA. And patients who ended up in the emergency department in dire straits didn’t get a huge bill at the end of their hospital stay. We could come up with a solution that facilitated getting bills out to Medicare or HRSA where they belonged, instead of those bills falling on the patient.

Building that kind of insurance discovery tool begins with managing CMS’s Medical Beneficiary Identifiers (MBIs) – the specific and unique numbers that represent each individual patient.

“In the past, CMS used patients’ Social Security numbers with an A on the end of it as the patient identifier. As you could imagine, that was a ripe opportunity for potential fraudulent behavior if malicious individuals got hold of that number,” said Quinn. “So, in 2020, CMS addressed the issue by implementing a new randomized patient identifier known as MBI.”

When CMS rolled out the new MBIs in early 2020, many providers lacked access to patients’ new MBI number, and, as a result, couldn’t bill claims. Providers needed a way to find the new number if necessary.

“Medicare is the primary payer in the nation, so not being able to find these identifiers caused significant issues for providers,” said Quinn. “Worse, patients sometimes had more than one MBI because if someone lost their number, they could just go to CMS and get assigned a new one. But we were able to solve this problem by using Inovalon to enhance a standard Medicare eligibility check. You can flag when the old Social Security-style number is used. And then you can use our vast data stores to find the specific match for a patient and deliver that back to providers to help them correctly verify that the patient has Medicare and then, more importantly, to bill Medicare for that patient.”

Shaw said that Invicta Health Solutions’ strategic partnership with Inovalon meant they could use Inovalon data to deliver these kinds of solutions to their provider clients.

“Inovalon built a back-end design for this,” he said. “Then we came to Inovalon and said we needed to scale this rapidly to give these providers some relief. Ultimately, we were able to take some of the Invicta technology, thread it into the Inovalon technology and then rapidly deploy that solution to our customers. And it made a huge impact.”

According to Quinn, providers with access to this insurance discovery tool saw a significant increase in reimbursements. To date, there have been more than 110 million MBI look-ups, with a successful hit rate of 60%.

Shaw agreed – and said that his clients appreciate being able to easily access MBIs upfront to streamline their billing processes. “You’re not going to have a good post-bill experience if your frontline team can’t do their job,” he said. “Giving your frontline team the technology to find these MBIs and to be confident in that information is really important. It means they will get fewer denials. And if they do get a denial, they can come to us and ask if the information is accurate, and we can give them an answer in real time, so they know what to do next. That’s the power of this kind of partnership.

Quinn said that having partners like Invicta and healthcare providers to guide them is key to helping Inovalon develop tools that make a real difference for both providers and patients. Hospitals are seeing benefits to their bottom lines. Patients are not being burdened with undue financial responsibility for care.

“We want to partner with the people who are closest to healthcare so we can have a better idea of where the industry is heading and what the needs are,” he said. “When healthcare organizations come together, not only are reimbursement issues being solved at the provider level, but patients’ lives are made easier by putting financial responsibility on the payer.”

Considering the unparalleled level of data Inovalon provides to partners like Invicta, there are likely dozens of new solutions that can be developed based on the claims information it contains. For example, Inovalon’s newest release is a standards-based API using the FHIR® standard that delivers longitudinally based, identified patient data to help providers make more informed clinical decisions at the point of care.

“Having access to all this data allows me to go to my clients and say, ‘Where is your pain point right now?’ so they can put me to work,” he said. “When you have access to over 280 billion unique medical transactions, over 200 million unique patient lives, you have an exceptional base for developing amazing solutions for the industry. You are in a position to make healthcare better. And that’s what we all want.”