Here at Advent, our expertise as a solution provider in the healthcare ecosystem is to convert clinical information to FHIR® standard and provide an open API that allows its exchange between payers and providers, effectuating efficiency and reduced administrative costs in the claims process. We understand the nuances of the healthcare claims review process and recognize the opportunity to provide solutions as a part of the overall interoperability initiatives that align with our company mission to remove the administrative burden from the healthcare claims review process.
Sharing Data Saves Lives
The technological advancement that drives the CMS Mandate for healthcare interoperability has a promising tagline: Sharing Data Saves Lives. With up-to-date medical information available at the touch of a screen, providers, health plans, and patients can communicate effectively, working together to determine appropriate and consistent health care.
“Having access to an interoperable health record is very important to us and to the receiving hospital to provide the best care possible to the patient. – Marty Fattig, CEO, Nemaha County Hospital, Auburn, Neb. –AHA Report.
Insurance Pre-Authorization
Streamlined, digital access to healthcare information decreases the administrative burden for both payers and providers in the insurance pre-authorization process. The standard pre-authorization process requires time for the provider to send the health plan information and then more time waiting to determine the status of that authorization. It’s a cumbersome system that costs the industry precious time and money while also delaying important patient care.
Leveraging modern FHIR® technology that integrates the plan directly with the EMR, information is sent automatically to the health plan, eliminating the need to file lengthy forms, as well as eliminating the long wait periods to complete the pre-authorization process. The flip side of this integration is that the health plan can also quickly provide feedback on the authorization status to providers. Not only does this diminish the administrative processing time between payer and provider, but it also decreases delays in a patient receiving treatment. Driven by technology, the process now allows clinicians and health plans to work together to deliver treatments and follow protocols consistent with coverage, minimizing healthcare costs and potential denials while also maintaining longitudinal patient records.
Medical Record Exchange Process
A 2020 report by Becker’s Health IT found that 71%-76% of medical records and information are still shared via fax and/or mail. These archaic methods have been costly across the healthcare ecosystem, from patients requesting access to their records to payers and providers navigating medical record retrieval/release processes for claims reviews. While Advent has been delivering technology solutions designed to streamline the claims review process for several years, the CMS healthcare interoperability mandate slated to begin taking effect in 2021 will likely catapult these efforts forward – including the development of many technologies related to creating and exchanging standardized FHIR® data.
The CMS Mandate is broad, but let’s focus on some of the ongoing challenges of the typical mail, fax, email, or portal sharing of PDFs (i.e., images) of patient medical records and other clinical information between health plans and hospitals.
- These costly methods of sharing records and information drain time, effort, and resources. Using a medical record claim review example, the payer (or a record retrieval vendor on its behalf) makes a retrieval request for records – typically within a batch request – and the provider (or a vendor on its behalf) releases those records. This process typically places an administrative burden on the provider’s team required to locate and capture those specific records. As if the locating and capturing process isn’t painful enough, fax machines, email providers, and online portals have file size limits that prevent complete files from being shared. Considering that lengthy inpatient hospital records can be hundreds or even thousands of pages long, file size limits are a challenge that run the risk of sending incomplete medical records via fax, email, or portal. Sending via mail assures that complete medical records are sent, but the process is painstakingly laborious and requires time spent preparing, boxing, and then shipping the records.
The administrative burden moves from the provider to the payer as the exchange of records occurs, and cases are now reviewed to determine reimbursement. The challenge in reviewing PDFs is metadata is often unavailable due to the traditional, non-digital exchange methods. Reviewing a PDF to find the needed data within the text can be a slow and burdensome process, especially with records that are hundreds or thousands of pages long.
The exchange method with the largest time-lapse between sharing medical records is via mail. This exchange method has most recently proven to be negatively affected by forces outside of the healthcare ecosystem, as the Covid pandemic has slowed USPS delivery, sometimes leaving mail sitting in their shipping centers for prolonged delays. Critical to claims resolutions with appropriate reimbursements is the provider’s ability to file, according to the payer’s timely filing policy. Slow transit times after the release of information can put a provider at risk of non-compliance with the payer’s timely filing requirements, potentially resulting in payment delay or denial.
CAVO® Connect Solves Pieces of the Interoperability Puzzle
CAVO® Connect delivers an innovative technological answer to the common shared challenge of the medical record exchange process between health plans and healthcare providers. Advent has built validated apps within the largest acute care EMRs to enable payers, without provider administrative burden after the implementation process, to seamlessly obtain the required medical record documentation and clinical data—at scale—to review, audit, and reimburse the claim timely and appropriately. Moving to FHIR standard data enables seamless data exchange between various entities across the healthcare ecosystem.
Next Steps
All of these components combined present a unique opportunity for the health care system, providing benefits to the payer, provider, and patient. With the integration of direct access to healthcare records via API, and standardized language converted to FHIR® standards, it’s estimated that the mandates could save the healthcare industry upwards of $30 billion per year