Solving medical record review challenges can be similar to a game of Tetris – you have to manage your resources carefully to productively complete medical records and itemized bill reviews properly. A survey we issued recently asked 450 people what method their team used to obtain medical records and itemized bills. The majority of respondents said that their internal team obtains the records and IBs, while a few responded that they receive this information through EMR data or by using an ROI company. A small minority said that they were unable to receive this information.
Often, EMR data is view-only and only provided in some instances. For example, EMR access is granted for utilization review, but not DRG audits. EMRs add additional functionality for health plans, but it comes at a high cost and a robust implementation. Another issue is that view-only access limits the payer from using technology to streamline the audit process.
Requesting medical records can cost between $25 – $50 per record, which is not only costly, but it’s also time-consuming leading to inefficiency. This leads to a lot of issues, especially at a time when there is a push to conduct prepay reviews.
So how do we get those records? And how can we review them quickly?
FHIR Data
Fast Healthcare Interoperability Resources, or FHIR, is a standard for the electronic exchange of healthcare information. There are specific calls that FHIR helps structure information, including a document reference call; the document reference returns highly variable clinical notes like discharge summary presented in either XML or PDF format. FHIR can turn observations like labs and vital signs. One of the benefits of using FHIR is that an item, like white blood cell counts, will have discrete information included – like the blood count and the reference range. Ingesting this rich data will catapult the analytics necessary to streamline the medical record review process and improve claim selection.
CMS has spent the last three years pushing interoperability and continuing care from one hospital system to another, made possible through various API software programs. Major EMR systems like Epic and Cerner create these APIs to allow medical systems to pull and extract clinical data. The benefits that FHIR brings to the mix are the structure and standardization of those API systems across the industry. When there is standardization, there is much less variability. The reduction in variability leads to a quicker and more efficient review process. Making this information available in an API means that plans can access needed information at the time of billing, which reduces time to revenue for the provider.
This technology becoming available through various APIs is paving the way for industry-wide automation. The structure around data is critical in decreasing the overall claims review process. The proper design leads to an overall better process, reduces payment errors, and sees quicker revenue across the industry.
In this webinar replay, join our team as they tackle obtaining medical records and IBs in a simple, efficient manner.
How Advent Can Help
Advent Health Partners has solutions to reduce your organization’s time to revenue and improve efficiency across the board. Our technology-driven platform has an open API and a HIPAA-complaint-certified framework. Our team has strong clinical and claims knowledge to assist your organization with mapping between siloed systems and minimizing payer investment.
CAVO Connect is a tool to enable organizations to seamlessly access medical records, itemized bills, and additional clinical data without provider administrative burden. CAVO Connect uses the latest FHIR calls to facilitate data interoperability, eliminates duplicate requests, and negates the need to chase down medical records due to its easily searchable and organized platform.
To learn how CAVO can scale up your payment integrity reviews, schedule a 20-minute demo with our team.