Master Files, the Beauty and the Beast of Application Management
By Diane Walizer
Engagement Manager
Beacon Partners, Inc.

The complex needs of supporting health care systems are staggering. Implementing HIPAA standards will increase the burden on health care applications. With so much riding on the applications, organizations need to pay close attention to the maintenance of the Master Files, a/k/a dictionaries.

As consultants, we are often called upon to resolve a problem that has been identified based on invalid results. These are examples of problem statements that we hear from our clients:

• The interface is not sending or receiving the correct information
• These patients did not appear on the daily visit list
• These claims should not have passed the claim edits
• These claims do not have the correct data translations
• This report contains invalid information
• This report is missing essential data
• The electronic request for these medical records did not occur
  
  

To determine the cause of the problem, we identify the logic under which the condition should work and apply it to the problem records. The most likely culprit is lack of integrity in one or more of the Master Files.

The Master Files are the files that contain information that support one or more applications. Some examples of master files are:

• Providers
• Provider charges
• Revenue centers
• Payers
• CPT codes
• Diagnosis (ICD9) codes
• Locations
  
  

Master Files support the functionality of an application. There can be many fields within each Master File. The individual fields are used to support data entry, interfaces, automated routines, and reports. If these fields lack integrity, the functionality that they support will not provide the expected results.

When the initial implementation or development occurs, the Master Files are reviewed to ensure that the fields within the file specific to the implementation or development contain valid information. Over the course of time these values can change, e.g., procedure codes that are identified as requiring a description of services on the claim to the payer no longer require the description. New records can be added that do not include the appropriate values necessary to support the original implementation design. In addition, the processes that the fields were intended to support can and will change. Therefore, the rules regarding the entries in the Master Files need to be re-evaluated.

With the integrity of the applications riding on the Master Files, how can this integrity be ensured? For starters, an effective Master File maintenance plan must be implemented.

An effective maintenance plan includes:

• Well-documented files
• Schedules for recurring and periodic updates
• Methodology to validate the entries
• File specifications for adding and changing the entries within the file
  

The documentation should include:

• The purpose of each field
• The owner of each field
• The acceptable values for the field
  
  

The purpose of each field should include the key functionality that is supported by the field, e.g., the provider identification numbers supplied by the payer are used to support claim logic. The owner of each field or file should be an individual who has the external responsibility to obtain and validate the data that goes into the file as well as determine the appropriate use of the information, e.g., the provider enrollment manager may be the “owner” of the provider dictionary. The key to the documentation is to ensure that the file is maintained in a consistent manner. Without consistent maintenance, the file may lose its integrity due to such issues as employee turnover, process change, and missed periodic updates.

There are files that require periodic updates. Some of the files that change annually are based on external sources. Examples include: Diagnosis Codes, CPT Codes, Modifiers, Payer Allowables, and Relative Value Units. Updating of these files should be scheduled into a work plan for review. The data should also be uploaded at the same time each year. This will ensure that the new values are available when they become effective. There are other Master Files that are supported from internal sources, such as Reporting Parameters, Charge Masters, and Provider Master Schedules. The active values in all Master Files should be validated at least once annually.

Once the documentation for each Master File has been established, a methodology to validate the entries can be created. Most vendors have built-in features that can be used to support the rules of data entry in the Master Files. Example rules include:

• Required fields
• Specific format for field value
• Branching logic (to complete additional fields depending on the response on a given field)
• Security
  
  

In addition to the support that the files themselves provide, additional reports should be developed to systematically check for fields that have either inappropriate or missing entries.

File specifications for adding and changing the entries within a file can be created from the documentation. These specifications can be in the form of online files or paper. Regardless of the format, the fields that are necessary for the integrity of all the processes supported by the entry should be included. The “field or file owners” must be held accountable to complete forms with the correct information prior to making a change within the Master File itself.

A Master File maintenance plan may appear to be logical, and certainly one would expect that this would be a given within any organization. However, it has been our experience that the documentation of the Master Files is forever on the “To Do List”. Meanwhile, the development of the application goes forward without establishing a clear file maintenance plan.

Today’s complex health care systems require a process to prevent many of the anomalies encountered during the daily updating and maintenance of their database systems. Implementing a Master File maintenance plan will allow the information systems and operations staff to work together to effectively support application integrity.

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About the Author
Diane Walizer has over eighteen years of experience in the health care industry. She provides guidance and hands on support for application assessment, design and implementation. Her expertise covers professional billing and scheduling systems as well as provider managed capitated insurance plans. As an Engagement Manager with Beacon Partners, Ms. Walizer is responsible for managing large projects and performing operational assessments. Ms. Walizer can be reached at 781-982-8400 ext. 452 or dwalizer@beaconpartners.com.

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