Payer-based care and utilization management programs are essential for managing member health, closing care gaps, and managing risk. Research data indicates that capturing members’ vast healthcare histories and normalizing that information for consumption can enable a care management program that enhances the effectiveness of provider-based care initiatives.
Obviously, provider-based care plans and face-to-face clinician-patient relationships remain a cornerstone of effective healthcare, but the repository of healthcare data to which payers have access and the tools they have to manage it offers an important channel to improve care and reduce costs. The key to enabling this kind of evidence-based, plan-sponsored care program, and setting up high-quality synergistic care management relationships between providers and payers, is proper understanding of diagnoses, lab, drug, and claim coding.
CPT vs. LOINC: What are the Differences?
CPT is the terminology providers use to bill for procedures. When a provider codes for a procedure in CPT, while certain factors such as the length of a visit or the amount of time it takes to perform a procedure may be described in the code, there are many care-related specifics that are not necessarily reflected. On the other hand, LOINC, the coding language used to describe lab results, is very specific.
Mapping CPT to LOINC allows those looking at the CPT data to draw a path back to the much more detailed description of the lab work that was conducted. The results of the lab work, the type of lab work ordered, and even the different places at which tests were administered are all reflected in the LOINC code. Thus a LOINC code provides more details of what actually transpired for each procedure, rather than the CPT code’s surface description. A provider can better assess the necessary utilization and care management plan that best serves the patient for immediate and continued care. LOINC codes deliver insight into the provider’s order for the tests, the observation of the tests, and finally the result of the tests, bringing a three-dimensional view, in addition to the CPT code used for billing, of the patient’s health status and needs.
What Does Mapping Have to Do with Care Management?
Since mapping CPT to LOINC allows payers to gain far more insight into patient care histories, it allows for the creation of effective, targeted care management and utilization management programs based on a vast, robust repository of information. With CPT mapped to LOINC, plans can combine big data analytics with in-house medical expertise to monitor a patient’s overall health profile, and offer programs that keep patients healthier and reduce overall patient and plan costs.
How Does Payer-based Care Management Reach Its Goals?
A payer-based care or utilization management program structured around effectively mapped lab data can benefit patients and providers by:
- Reducing the burden on your staff by supporting your interoperability needs for data warehousing, clinical information exchanges, analytics and reporting, and population health initiatives.
- Letting a patient know the services that are available in his or her area above and beyond strictly clinical resources (for example, social services or patient support groups that could aid in a patient’s ability to effectively manage a condition and experience a better quality of life).
- Coordinating continuum of care for a patient regardless of the care provider (e.g., mental health, RX, physical therapy, nutrition, co-morbids).
Payers will continue to find new ways to organize their programs, but clear and understandable data is key to any care management plan, and is the answer for delivering quality, cost-effective, and accessible care.