Claims Automation In a New Environment
March 2005
When a physician refers a patient to a specialist, the patient often arrives at the specialist's office before the requisite clinical and administrative information. This is not a "dirty little secret" in health care. It's a fact of life.
St. Joseph Health System, however, is combating this problem by using electronic data interchange technology to automate the flow of information among physicians. It's rolling out Web-based referral management software from Irving, Texas-based Healthvision Inc. And half of the delivery system's 300 primary care and family physicians already are using it.
The software automates verification of eligibility for specialist treatment, transmits the referral request to a utilization review manager if necessary, and automatically updates St. Joseph's practice management software, says Larry Stofko, vice president of strategy and innovation at the Orange, Calif.-based delivery system. The software then links-via URL Web site addresses-transcribed reports, laboratory reports and other inpatient clinical data to the referral before transmitting it to the specialist.
Like St. Joseph Health, many other provider organizations are using EDI for far more than claims submission. For example, they're using EDI to check patient's insurance eligibility, to inquire about the status of a pending claim, and to receive and post electronic remittance advice to patient accounts.
One catalyst for the growth in these and other claims-related electronic transactions is the HIPAA transactions and code sets rule. But the promised cost-saving benefits of the HIPAA rule's so-called "standards" have not yet fully materialized-nor will they until the transactions are truly standardized, many experts say.
"I'm in meetings where someone asks, `Aren't these already standardized, since we did all that work?'" laments Stofko. "And the answer is `No'".
The HIPAA rule actually permits payers to add optional data elements to standard electronic claim forms, resulting in hundreds of versions of a "standard" format and hampering the industry's ability to improve efficiency through standardized claims. Consequently, some observers fear that the proposed national health information network would not yield anticipated efficiencies unless its voluntary standard clinical data elements become mandatory.
Competitive landscape
In recent years, there's been a slow, steady shift toward providers submitting claims to payers directly over the Internet, bypassing claims clearinghouses. But still, the vast majority of claims travel from a hospital or a clinic to a clearinghouse, which typically edits claims and then routes them to appropriate payers. And many clearinghouses are handling a growing list of claims-related transactions and offering other new services in hopes of convincing providers not to file claims directly via the Internet.
One change last year in the claims clearinghouse competitive landscape could have major consequences.
Elmwood Park, N.J.-based WebMD Corp., which operates the nation's largest claims clearinghouse, is changing its business relationships with other clearinghouses.
For many years, these other clearinghouses have routinely routed claims destined for certain payers through the WebMD clearinghouse, which has served as an extra middleman. That's because the WebMD clearinghouse (formerly known as Envoy and NEIC) has well-established links to these insurers, some of which date back to the 1980s.
In the past, the other clearinghouses shared in the transactions fees that WebMD received from payers. But last year, WebMD signed "exclusive" or "near-exclusive" contracts with at least 10 payers. These include Aetna Inc., Cigna Healthcare, Horizon Blue Cross and Blue Shield, John Deere Health and Medical Mutual of Ohio.
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