Case Study
A $15B Medicaid MCO struggled with duplicate member records across multiple systems, facing millions in potential HIPAA fines, delayed prior authorizations, and inaccurate risk adjustment coding.
DataCatalyst implemented an MDM platform, creating golden patient records by linking healthcare identifiers, with specialized workflows ensuring HIPAA compliance and regulatory validation.
The organization achieved a 75% projected reduction in claim denials, significantly faster prior authorizations, and projected annual savings of $25 million while establishing a foundation for future data initiatives.
A $15 billion Medicaid Managed Care Organization (MCO) was drowning in data chaos. As a healthcare payer administering benefits to thousands of members, they operated a complex ecosystem of over a dozen different systems – including EHR/EMR platforms, claims adjudication, member enrollment, and provider portals. With more than 40 stakeholders involved in various data processes, their information environment had become fragmented and increasingly unmanageable.
The MCO had reached a critical breaking point. Duplicate member records proliferated across their claims, eligibility, and care management systems, creating serious operational inefficiencies and compliance vulnerabilities. These inconsistencies weren’t just administrative headaches – they directly impacted patient care, with mismatched IDs causing delayed prior authorizations and worsening health outcomes.
The organization desperately needed a single, accurate view of each member across all systems to ensure proper care coordination, accurate billing, and regulatory compliance. Without this foundation, they faced tens of millions in potential HIPAA fines, CMS audit failures, and continued financial penalties from inaccurate risk adjustment coding (HCC).
DataCatalyst deployed a lean team of data management experts who immediately began working with the MCO’s stakeholders to assess the full scope of their data challenges. Following our Accelerate methodology, we conducted a thorough analysis of their data landscape, mapping flows across their dozen-plus systems and identifying critical points where inconsistencies occurred.
Rather than proposing a massive, multi-year transformation, we focused on delivering high-impact value quickly. Our collaborative workshops with over 40 stakeholders across the organization helped build consensus on priorities and ensured the solution would align perfectly with business needs – not just technical requirements.
Based on the diagnostic process, DataCatalyst implemented an MDM platform that created golden patient records by linking Medicaid IDs, provider NPIs, and ICD-10 codes. This centralized approach established a single source of truth for member information while accommodating the complex healthcare data environment.
Key components of the solution included:
Implementing this solution required significant but focused changes to the organization’s data management practices. The MCO shifted from siloed data management to a centralized approach with new processes and workflows.
Our change management expertise was essential during this transition, as stakeholders across the organization needed to adopt new practices for data entry, validation, and management.
Despite the complexity of integrating multiple healthcare data standards and ensuring compliance with both HIPAA and CMS requirements, our Accelerate methodology kept the implementation on track and delivered value in phases, rather than waiting for a “big bang” deployment.
The transformation delivered substantial and measurable results with remarkable speed:
Overall, the new data management approach reduces regulatory compliance issues, improves operational efficiency, and enhances patient care through faster authorizations.
The MDM implementation fundamentally transformed how the MCO manages its member data, creating a foundation for ongoing innovation and improvement. With their new data management capabilities, the organization is now positioned to:
The MCO has established the data foundation necessary to thrive in an increasingly complex healthcare landscape.