Breaking down the patient journey: When to use open vs. closed claims data

When you need to understand a patient's healthcare journey, medical claims data can help you identify where they are on their journey as well as the various care encounters they've had along the way. Claims are categorized as open or closed claims, and while both types of claims data can provide useful information, you'll get the most valuable insights when you use the right type of data for the task.

What's the difference between open and closed claims data?

Both types of claims data have a place in your patient engagement strategy, but how do they differ?

Open claims data comes from a diverse range of healthcare sources. This type of claims data offers information on a patient's activities over a long period of time, no matter who their insurance provider is. However, it is often limited to providers within the same clearinghouse.

In comparison, closed claims data comes from health insurance providers, also known as payors. This type of data unveils nearly all of a patient's activities in the healthcare system within a certain enrollment timeframe.

Open claims data

Open claims data includes all medical and pharmacy claims for a patient and is most often sourced from pharmacies, clearinghouses, and software platforms. These claims can also include other data types from non-payor sources, as well.

There are two types of open claims data:

• Open medical claims can be acquired through billing systems, practice management systems (PMS) (when recording patient visits), reimbursement requests, and more.
• Open pharmacy claims are captured by pharmacy benefits managers (PBMs) and in pharmacy management systems.

Open claims can encompass many different data types, which makes them crucial sources of insights into patient touchpoints across the entire healthcare landscape. The greatest advantage of open claims data is that they aren't limited to a specific time frame, providing plenty of utility for long-term analysis.

Insights offered by open claims data

Open claims data can be used to understand a patient's interactions throughout the healthcare system. This type of claim support prompt reporting and tracking because many medical, lab, and pharmacy visits in open claims data are available before adjudication. Some of the available open claims data include CPT and ICD-10 codes, physician details, billing, referring NPR, and service locations.

Other uses for open claims data include:

• Regulatory compliance
• Optimizing clinical trials
• Value-based agreements
• HEOR
• Marketing strategies
• Data management

Closed claims data

Closed claims data is derived directly from insurance providers and documents nearly all patient events during their enrollment period. This can include medical and pharmacy encounters, hospital admissions, urgent care clinics, and retail and specialty pharmacies.

There is a limitation to closed claims data, though: it only captures the patient's health journey while they are with one health insurance provider. If a patient switches providers, additional interactions may not be captured, limiting data continuity across different insurance plans.

Insights offered by closed claims data

You can use closed claims data to get a detailed look into the patient's journey, which can help with linking diagnoses, decisions, and actions. One of the most impactful uses for this full-picture view of a patient's health journey is the ability to track their adherence to treatment.

Tracking treatment adherence can be crucial for providers and their partners. Treatment adherence not only supports improved patient outcomes and reduced hospital readmissions, but also affects resource usage and costs. By tracking treatment adherence, providers can direct additional support and resources toward non-adherent patients and adjust their care plans to make adherence easier.

Combining both types of claims data

To achieve the most comprehensive analysis, you'll need to combine both open and closed claims data. Doing so allows you to explore patient behaviors and treatments at any point in their enrollment period, but also beforehand and afterward, enriching your insights into diagnoses, patient behaviors, treatments, and adherence. As such, both data types are crucial for patient-centric research. Open claims are useful for longitudinal analysis, while closed claims offer a concise snapshot for a specific period.

Claims data in action

To help you understand the uses and limitations of each data type, here's an example scenario:

A patient sees three different doctors for a range of medical issues. Two of those doctors, the primary care physician and rheumatologist, have their data captured by an open claims dataset, while the third doctor, a cardiologist, uses a different clearinghouse.

So long as the patient sees the same primary care physician and rheumatologist, open claims will acquire the data, no matter their insurance provider. However, since the cardiologist is not part of the same clearinghouse, that data is not included within the open claims dataset, so anyone analyzing this data may never "see" the visits to this doctor.

Attempting to follow a patient's healthcare journey with open claims data alone can produce gaps and uncertainty because the percentage of interactions that are included is rarely clear.

With closed claims data, information from all three doctors is included, but only for a select enrollment period. If the patient were to start a new job and enroll in a new health insurance policy, they may no longer be visible under a closed payor claims dataset.

Learn more

It should be clear that each type of claims data has its benefits. Making use of both can provide even greater insights into a patient's care journey, enabling healthcare organizations to trace referral patterns, refine sales targeting, improve population health, and accelerate their go to market strategy.

If you're ready to get access to robust claims data, provider reference and affiliation data, and powerful analytics, sign up for a demo of our healthcare commercial intelligence platform.

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