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Information drives three key processes – scheduling patients for health care services, determiningand verifying their insurance benefits, and registering them. The quality of informationgathered throughout the continuum of care can make or break these processes.

Nowhere is the flow of information more critical than in the fundamental processes that control patient access to health care services. Payers gather and maintain information from employers and members. They, and member patients, provide that information to providers. Out-of-date, incomplete, or otherwise inaccurate information creates an administrative nightmare for everyone that ultimately threatens business success, either through decreased revenues or increased costs. At worst, when incorrect information makes a patient ineligible, the ultimate consumer of health care services finds himself caught in the middle.

Information flow transcends what at first glance may appear to be a simple matter of technology. We expect a great deal from information technology, hoping it will serve as a quick fix for process and people problems. These expectations have heightened as a result of significant and impressive advances in information technology and systems. HIPAA regulations have raised our expectations even further by legislating standards for technologies and processes to exchange eligibility and benefit information.

In fact, without a focus on the continuum of information – what and how information moves from, to, and through processes – technology can complicate processes and aggravate patients, providers, and payers. Integrating HIPAA requirements, for example, won’t correct the drawbacks of processes that create inconsistent information.

People, processes, and technology must work together smoothly for scheduling, eligibility, and registration to work smoothly. Collaboration between payers and providers promises to unite people, processes, and technology for shared success – with a favorable impact on the consumer.

Key Processes, and The Information That Controls Them

Information flows through enrollment, scheduling, eligibility, and registration processes. Payers gather fundamental information from employers and members during enrollment, and update and maintain that information. Physicians then provide more information related to a particular episode of care. Payers respond with information about whether the member/patient’s health plan covers that particular episode, and this exchange continues if the original episode evolves into longer-term care. The specifics of departmental and process nomenclature may vary from organization to organization, but the fundamental processes remain the same.

The areas of scheduling, eligibility, and registration fall primarily within the key payer-provider collaborative process model of market development and maintenance described and illustrated (as Figure 6) in the white paper “A Framework for Collaboration: The Process Model.” Enrollment activities fall within the manage patient and member financial services key process described and illustrated as Figure 8 in the white paper “A Framework for Collaboration: The Process Model.”

Payers build benefit file structures, set up benefit files, and enroll members (employees and their dependents) generally on behalf of an employer or sponsoring organization. They maintain data about membership and benefits with information databases and files. This includes making changes to benefit and member information that directly reflect status. Ideally, this process insures up-to-date profiles of member demographic and eligibility information as it relates to the plan of benefits. In many cases, however, payers have limited control over this information.

From a benefits perspective, most payers develop standard benefit plans, but self-insured employers (those who take financial risks for their own medical costs) often sculpt unique benefit plans. This creates more, rather than less, variation. The proliferation of consumer-directed products adds more variation to benefit plan design. As a result, an overall lack of standardization can lead to service challenges.

From a membership perspective, patients and payers often depend on employers to provide updates to membership data. (They may also receive updates directly from members.) Though the use of automated approaches has increased in recent years, information gathering remains dependent on phone calls, paper, and other manually intense techniques. This frequently affects the currency and accuracy of the information at payers’ fingertips when interacting with providers to determine eligibility. Process inefficiencies can affect information on a payer’s Web site, for example, complicating verification of benefits.

Although the payer is not always in the driver’s seat, technology can help solve problems, particularly if the employer group takes meaningful ownership of enrollment and eligibility information. In Massachusetts, a group of payers and providers have partnered proactively to allow access to their employee/dependent membership data. Such an approach can take the form of direct access to the payer membership systems or the use of other automated approaches such as Web access or file transfer. Improved information access benefits the employer group and the payer. The employer group has direct control over the eligibility data that drives its invoice from the payer. The payer avoids transaction costs associated with entering, updating, and maintaining data. Everyone (including provider and patient) benefits from timely access to accurate information.

The next steps, in which providers determine benefit liability, potentially create the most contention between payers and providers but also offer the greatest opportunities for collaboration.

Providers register patients when they present for medical services to ensure they have complete and accurate demographic, insurance, and clinical information for those patients. This is true for scheduled and unscheduled services, or in the case of a walk-in. Sometimes, registration serves as a simple check-in following a more detailed preregistration process. Other times, the provider requires the patient to completely review and verify all information at the time of registration.

At registration, the provider enters the event into its scheduling system, based on the presence of the proper authorizations and referrals. Despite this, a scheduled event does not automatically create data in the provider’s patient management system. Separate systems require redundant entry and create the potential for incorrect or missing information.

Benefit determination is critical to providers, who want to know what services will be covered and by whom (the patient and/or single or multiple payers) at the beginning of the process. The likelihood of obtaining payment on undetermined services or procedures is much lower for providers if they cannot resolve issues at the front end of the process. Bad debt plagues providers, who write off millions of dollars every year due to unresolved charges. Moreover, customer satisfaction with payers and providers declines when patients find themselves caught in the middle of disagreements over unresolved charges.

The quality of information gathered by payers and providers determines whether a particular patient has active insurance and whether that insurance covers the proposed procedures and services. It also affects the ease with which providers obtain authorization for procedures and services. Something as simple as an inconsistent name spelling or code can create costly delays and administrative rework for payers and providers. About 80 to 90 percent of the information required for physician billing also serves as the majority of information for hospital billing. This suggests potential for meaningful physician-hospital collaboration as physicians may have resolved information conflicts with payers.

Further complicating matters, benefit plans often have limits on dollars or services (or both) – out-of-pocket maximums and/or the number of behavioral health outpatient visits, for example. Accumulation toward these limits changes as payers process relevant claims, so yesterday’s data may not be accurate today. Inconsistencies also complicate processes farther along the continuum, such as accounts receivable and accounts payable. (The white paper “Accounts Receivable Management” discusses these processes in greater detail.)

Today, interaction about eligibility and benefit determination often takes the shape of a phone call, either in person or through intelligent call routing. Web portal interchange for transactions has gained growing acceptance, as have Web-based clearinghouses such as WebMD and PerSe, but in many cases providers bypass clearinghouses if a significant amount of traffic warrants direct connection with payers. In all cases, staff time, transaction fees, and other costs can add up considerably when information exchanged by payers and providers clashes.

Opportunities for Collaboration

Collaboration in various degrees, from improving connectivity to true collaboration over process design and implementation, vastly enhances the quality of information exchanged from enrollment through scheduling. Collaboration also tends to speed information access. By combining perspectives and resources in a collaborative way, payers and providers can improve the quality of information related to eligibility, benefits, and coordination of benefits (see Figure 1).

Figure 1. Eligibility, Benefits Verification, and Coordination of Benefits

In the coming years, provider and payer systems will become more compliant with HIPAA regulations, bringing more standardization to the health care industry. This will provide opportunities to assess respective processes and infrastructures, revise methods, and update electronic transaction technologies. Collaboratively assessing situations and developing and implementing new approaches can dramatically improve performance.

Another opportunity for collaboration involves payer Web portals that enable providers to access information online, essentially automating eligibility and benefit verification, authorizations for payments of medical services, and other important activities. By working together to determine how providers access and use benefits information, payers and providers can reduce costly and inefficient telephone and other inquiries, registration and scheduling delays, and claims delays and denials.

If payers provide enrollment lists and other information to providers electronically (and frequently update that data), providers can integrate that information into their own databases and have all the information they need within their own systems. This way, changes to core information arrive further in advance of eligibility verification, registration, and scheduling. Again, costly inquiries drop, with associated reductions in administrative costs. A fringe benefit of this approach is the ability of providers to reach members with regular reminders of wellness plan procedures and services.

Collaboration at Work

Michigan health care providers and a major payer have collaborated for a number of years in the area of eligibility, benefits verification, and COB. They developed new procedures and technologies to reduce COB rejections. They also created a mechanism for allowing providers to document and submit coverage information, which has improved their access to COB and eligibility information and enabled automated insurance verification. They continue to work together to identify and implement best practices for preregistration processes, eligibility and benefits verification, and coordination of benefits. The result of this collaborative effort has significantly reduced rejection rates at all hospitals, and decreased the payer’s accounts receivable.

Highmark Inc. and the University of Pittsburgh Medical Center Health System have collaborated on a significant technology initiative to address similar issues. Highmark has pledged to invest $20 million over 10 years in joint efforts to consolidate and integrate operations. The effort will more efficiently link providers and payers through the enrollment, eligibility, registration, and scheduling processes. It also will combine HIPAA compliance efforts and those required by other government regulations. See the white paper “A Success Story” for a case study of the Highmark project.

In Massachusetts, where more than 70 percent of the health care in the state is insured by locally based health plans, payers and providers have a history of cooperation and collaboration on information technology initiatives. The New England Healthcare EDI Network (NEHEN) is one result. A regionally based private network, NEHEN uses standards to transmit health care administrative transactions. Providers can use one mechanism and format for routine transactions to multiple payers.

Another payer, with 15 million medical members and 46 million specialty members nationwide, has created an initiative to improve eligibility, benefit verification, and coordination of benefits. This effort will enable more real-time eligibility information, create a single point of contact to resolve COB issues, and ensure that all parties understand primary and secondary insurance coverage issues. The payer will develop processes to capture and update eligibility information from employers on a routine and real-time basis, better manage COB payments, improve benefits verification, and move toward online provision of eligibility information. Members of its provider network will focus on enabling verification of eligibility and benefits information at registration, comparing verified benefits with contract models, and identifying COB accounts at preregistration and/or registration and billing for those accounts.

These examples of collaboration demonstrate that improving the quality of information and its flow from enrollment through scheduling works best when people and processes drive technology implementation. At the end of the day, the benefits of collaboration transcend process improvement. They lead to enhanced customer satisfaction that leads to a better bottom line – and to increased market share – for payers and providers.