PDF File: 

HCT3_wp_mcnabb.pdf

Accenture

To strengthen the connections between patient systems and payer claim systems, healthcare organizationsneed to integrate their technologies by modernizing their legacy systems.

In most provider offices today, the patient accounting system is the beginning of the electronic healthcare transaction.When patients arrive, their information is automatically entered or updated in the provider’s patient accounting system. Physician notes on the patient’s examination are reviewed by an assistant who turns key aspects of the patient’s visit into a claim (e.g., clinical and financial information), which is then transmitted via the accounting system to the payer for reimbursement.

Currently information flows between the provider and the payer as claimable events.When a claim is created, only then is clinical and financial information sent to the payer.

Because insurance companies now require more detailed information for claims processing, transposition and interpretative errors are more likely to occur between the provider’s chart reviews and data entry, and the payer’s claim coding standards. The provider’s administrative staff can cut corners to save time and avoid hassles, or code claims that favor the patient’s benefits.

Due to the lack of integration between payers’ and providers’ systems, the quality and transmission of information is less than desirable. Payers spend too much time assessing claim submissions, providers aren’t compensated as rapidly as they’d like and patients often can’t make prompt or informed decisions about their care.

Bringing Technology to the Point of Care

Electronic integration can minimize these flaws. By improving the links among the EHR, patient accounting and the payer systems, information events can be created based on patient health events instead of merely financial events. A claim can be automatically populated with the correct data, resulting in a higher-quality, more timely flow of information. Payers and providers both can reduce administrative costs and errors and optimize patient care.

Payers and providers can strengthen the connections to each other’s systems by upgrading the technology used within their own organizations. The reality, however, is that most companies have made considerable investments in their legacy systems, and the costs incurred from those installations will prevent many of them from purchasing entirely new systems. Very few establishments, if any, have the internal resources to create their own systems. In order to achieve legacy integration, this leaves most organizations with the only option of modernizing their legacy systems.

Healthcare providers are becoming more aware that system upgrades will soon be a necessity instead of a consideration. The Bush administration has set an ambitious goal of ensuring every American has an accessible EHR on a nationwide network within the next 10 years. It wants the healthcare industry to adopt technologies that deliver information to the point of care, especially by investing in EHR systems. The desired result, an interoperable health information infrastructure, will enable records to follow patients, clinicians to have access to information when decisions are being made and patients to become more involved in their own health decisions. This mandate, driven by the federal government’s size and position as a healthcare provider and purchaser, will accelerate industry’s adoption of information technology.

Opportunities for Improvement

By strengthening the connections between the EHR, patient accounting and payer systems, payers and providers can meet the government’s mandate. As the quality and timeliness of data improve, new options for customer service and care delivery will also emerge, including:

• Explanation of benefits and an adjudicated claim at the point of care;
• Predetermination intelligence to assist the provider and patient when they make financial and clinical choices; the physician can view the patient’s EHR and benefits to advise on available benefit options, drug formulary, preauthorization requirements and care delivery options; and
• Better self-service options for all stakeholders.

An ideal model to follow is similar to “e-prescription” solutions. Today the pharmaceutical business vies to obtain constant feedback on data generated from patient prescriptions. In a typical e-prescription situation, the provider enters a suggested prescription for arthritis into a handheld computer. In seconds, the computer screen displays the leading brand-name prescription’s cost at $40, and the generic version’s cost as half the price. The realtime information gives both the provider and patient real-time access to information that allows them to make intelligent choices involving both cost and care based on the patient’s benefit plan.

Implications of Legacy Modernization

Historically at odds with each other, payers and providers will become more intertwined on the operations level and will benefit from the closer relationship. Payers will be more agreeable to compensate providers for higher-quality data. They will order endto- end transactions, giving providers more incentives to contract with them and share the same automated systems.With updated legacy systems, the provider office will need less manual intervention and, therefore, less administrative support to maintain its reimbursement processes.

Because payers hold the most financial capital, they will be most responsible for legacy modernization. But they will reap the most benefits from an automated loop of information, which support improved medical outcomes and allows provider and payers to simplify their coding and reimbursement processes. The Bush administration’s mandate means that quality of health information will become more critical during the next five to 10 years. As a primary stakeholder with the extensive repositories of data that can provide statistical outcomes on medical results, the payer will enjoy higher value-added propositions. If procedures have better statistical and financial outcomes, providers will become more dependent on payers to gain access to the data.

Successful Legacy Implementation

In recent years, legacy modernization has provided the most costeffective approach for payers. Legacy modernization accords lower costs and higher comfort zones for payers with definitive levels of risk. By modernizing existing systems, companies have been able to reduce their information technology costs by 20 to 40 percent.

Healthcare leaders must resist the temptation to view healthcare records as an unconnected entity. Instead, they must take a more organic view and consider how their records will integrate with existing business processes.

A payer selecting an outside vendor should first evaluate its own technical strengths and weaknesses, and then select a vendor based on how the collaboration can improve its overall system. Then it must be willing to commit adequate funds. But simply throwing money at the vendor — paying generous fees without assessing the vendor’s technological competencies and deficiencies beforehand — will likely be throwing money away.

Every successful innovation requires both leaders and followers. Leaders will take the risk and reap the early benefits, while the riskaverse will move forward at a later date when standards are determined and end results are a fixed outcome. Payers and providers have historically lagged behind in legacy integration because they have lacked a financial incentive. But now, with Europe taking the lead on the EHR initiative and the federal government becoming more intent on redefining the healthcare delivery problem, linking health records will soon be critical to the financial success both of payers and providers, instead of a selective option.

The Real-Time Conclusion

How can the payer world move forward? They must upgrade to real-time systems that record and utilize EHRs within the provider’s accounting structures and the payer’s own information databases. The ideal scenario of the future has a patient receiving an explanation of health benefits from the insurer while still in the provider’s office. Each stakeholder will make intelligent use of real-time data — payers can interpret it, providers can use it to advise patients, and patients can use it to make reasoned care and financial choices.

The process of technological modernization involves considerable costs, not the least of which is the risk of early entry while standards are evolving — and the potential cost of retooling the system. No one wants to be the guinea pig when enforcement of electronic standards is still being debated. In other countries, nationalized care is modernizing healthcare systems to make electronic automation the status quo, albeit with government funding. But as the Bush administration moves forward on its plan for EHR nationwide, the for-profit healthcare industry must eventually upgrade its technology to account for real-time management of patient information. In the long term however, modernizing technology — most likely legacy integration — will reward the parties involved, with lower costs, higher-quality data, decreased errors, improved clinical and business work-flow processes and superior patient care and outcomes.