This document describes developing a dashboard to monitor the pharmacy reimbursement cycle for a healthcare organization. It outlines establishing a performance metrics committee, identifying relevant transactional data sources, determining key measures and benchmarks. It then provides a case study of a pharmacy services company, PharMerica, outlining the logical and physical design of a dashboard to monitor admissions, adjudication, billing, and collections processes across its eight regional business offices. Specific query files, criteria, measures, statistics, and targets are defined for each process.

1. Developing a Dashboard to Monitor
the Reimbursement Cycle in
Healthcare
Case Study: Monitoring Pharmacy
Measures for Admissions,
Adjudication, Billing Services and
Collections

2. Content
• Method
• Logical Design
• Physical Design
• Case Study
• Data Transformation
• Implementation

3. Method
• Establish Performance Metrics Committee
• Identify Transactional Data
• Determine Measures & Benchmarks
• Create New Data Source
• Develop Front-end for Users

4. Performance Metric Committee
• Choose committee members from each
business function or process
• Identify measures for each process
• Gauge the impact for each measure and set
benchmarks/metrics

5. Transactional Data
• Dashboards use daily transactional data to
measure impact of workflow or processes
• Transactional data must be easily obtainable
• Data should be summarized to aggregate
levels
• The interface between the data source and
dashboard should be seamless

6. Measures & Benchmarks
• Measures should indicate financial,
productive, efficiency or quality impact on
the business process
• Measures should easily roll-up to
summarize or drill-down for detail

7. Data Source
• Data should be transactional data
• Source must be a relational database
• Database tables should have primary keys
that are easily joined

8. Logical Design
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9. Ltceast1.ws
Dashboard
ODBC
LTC400
Query
Physical Design
MSQuery
Pharmacy RBO
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10. Case Study
PharMerica a subsidiary of
AmeriSourceBergen

11. Background
• PharMerica is an institutional pharmacy
service with 83 pharmacies, nationally
• Eight regional business offices RBOs
serving 83 pharmacies
• Each RBO provides admissions,
adjudication, billing and collections

12. Admissions
Query Files
• T01 POE Billing File
• T02 Resident File
• T03 Resident Drug Billing
Hierarchy
• T04 Pharmacy Order
Entry File
Criteria
• T01.Financial Plan equal
to NEW, NUADD or
PEND
• T03.Thru Date = zero
• T01.Include all record
were date-of-service equal
to or greater than current
calendar year
• T01 Billing Amount > 0

13. Ltccent.as4
new resident
PEND
Verify Payor
Source and change
Hierarchy Status
Pharmacy enters resident
Status information in
POE Billing
File as PEND and a zero
thru date
Admissions coordinator
Verifies payor source, updates
hierarchy and enters a
thru date for resident
Admissions
PEND status is removed
once thru date is no longer
equal to zero

14. Claim Denials
Query Files
• T01 OmniSYS claim file
• T02 Adjudication Reject
File
• T03 POE Billing File
Criteria
• T01. Current conditions
equal to INER or DEND
status
• T01.Include all records
from any date-of-service
• The financial plan in file
T01 must equal the plan
in file T03
• T03.Billing Amount > 0

15. Manual Billing
Query Files
• T01 OmniSYS claim file
• T02 POE Billing File
Criteria
• T01.Current conditions
equal to 'REMN' 'MNAP'
'MCLM' 'MBIL'
• T01.Include all records
from any date-of-service
• T02.Billing Amount
remaining > 0

16. Collections
Query Files
• T01 A/R Balance forward
file
• T02 Resident RP file
• T03 Resident File
• T04 Financial plan file
• T05 Facility File
Criteria
• T04.Payor source equal to
private
• T02. Find fields were the
responsible party
information is blank for
the address, city, state and
ZIP code
• T01.Residents last name
not equal to ‘House
Account’

17. Measures
PEND MANUAL
BILLING
POS
CLAIM
DENIALS
ERROR REVERSAL
DENIED
REVERSAL
APPROVED
Billed Amount
$
X X X X X X
Denial Codes
x
Manual Billing
Status x
Billing Date
x
Date-of-
Service x x

18. Statistics
PEND MANUAL
BILLING
POS CLAIM
DENIALS
ERROR REVERSAL
DENIED
REVERSAL
APPROVED
DSO X X
> 60 d X X
> 120 d X X
Targets > 48
HRS
1.5 ADR 0.25 ADR

19. Data Transformation
Developing AS/400 Query Scripts