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Making a Better Connection
January 1, 2008
This story is the first in an in-depth, three-part series Health Data Management will publish this year about I.T. innovations and trends in revenue cycle management. We'll also be running three other series of feature-length articles on electronic records, point-of-care technologies and CIO Issues. These series represent our effort to provide insightful, concise and timely information to our readers on the technologies and business issues that shape their strategic initiatives.
- Greg Gillespie, Publisher
Fifteen years ago, many hospitals and clinics were just beginning to communicate electronically with payers, replacing paper claims with electronic versions submitted in more than 400 proprietary formats over private networks.
Today, most claims are submitted electronically in the standard HIPAA-mandated format, with many traversing the Internet. And provider-payer electronic communication finally is expanding to include other transactions.
Among the fastest-growing transactions are insurance eligibility verification, remittance advice and funds transfers.
In addition, a handful of payers are taking the big step of adjudicating claims in real time, telling doctors within seconds of receiving the claim how much they will be paid and how much they should bill the patient.
This trend is driven, in part, by the growth in consumer-driven health plans, which place more of the burden for payment on the patient through higher deductibles and other factors.
Beyond financial transactions, many observers predict that in the years to come, providers and payers will be exchanging far more clinical data to support disease management efforts and quality improvement. Whether the same clearinghouses that serve as the conduit for claims and related transactions will handle this clinical data exchange remains uncertain. Also unclear is the role broader health information exchanges (or regional health information organizations) will play in all these transactions.
How Many Steps?
Since the very beginning of electronic claims processing, it's been common for a claim to go through several middlemen before reaching its destination at an insurance company. For several years, Aetna Inc., for example, required that all its claims had to be funneled through the clearinghouse of Emdeon Business Services, Nashville, Tenn. As a result, a clinic that served Aetna customers but used a regional clearinghouse might see its claims go from that clearinghouse to Emdeon before reaching Aetna.
In recent months, Aetna has announced it's accepting claims directly from several other clearinghouses, including RelayHealth and MD On-Line. Responding to demand from providers, the payer decided to offer them more flexibility in choosing which clearinghouses to use to submit electronic transactions, a company spokesman says.
The Aetna action is the signal of a trend, says Patrick Kennedy, partner at PJ Consulting, Rockville, Md. "Payers want to get closer to the doctors," he contends. "They want to work with the vendor who has the contract with the doctor. They want to ultimately be able to exchange more data directly with the doctor."
This desire for more direct connections reflects a long-term goal of exchanging clinical data for disease management, Kennedy says. "Payers want to be able to send clinical data to physicians," he explains. For example, he says they want to be able to send a message to remind physicians that a diabetic patient is due for a test.
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