The payment process is broken. Information isn't shared. There's no transparency. And it's hard for payers and providers to access what they need. But health care CIOs and IT leaders have the know-how to lead a transformation to a more integrated and useful system.
Frustration with verification of benefits and medical eligibility
Consider the verification of benefits and medical eligibility. When we've asked hospital and physician group leaders, they've told us the following are some of their biggest frustrations.
Most major electronic health records (EHRs) are good at identifying the current insurance status of patients. But it's usually impossible to know the precise amount of coverage and co-pay at point of care for specific orders or referrals. Health care providers simply can't tell if or how much an order is covered in the patient's plan.
It's a concern for payers too. Without accurate data exchange, payers lose the ability to use coverage determinations to help guide care to better quality or lower cost options. And payers spend even more on process and staffing than providers to adjudicate coverage questions.
Most important, patients are also in the dark, unsure whether treatments are covered and what their out-of-pocket cost will be.
Key steps to consider
Working together, payers and providers can build systems that support the up-front exchange of current and accurate data. This can include coverage information as well as information on multiple liabilities, third-party payers, primary payer determinations and more.
There is much work to be done to establish strategic relationships and technology solutions that can create a more integrated system.
Here are three steps CIOs and IT leaders can take to prepare for and support systemic changes in how health care organizations ingest and share data.
1. Engage EHR vendors
CIOs should let their EHR vendors know that seamless data exchange that allows for the benefits verification is a key priority.
EHRs are still the best way to reach caregivers at point of care. Most major EHR vendors are developing or enhancing the ability to take in payer data and use it to highlight eligibility requirements for providers. Many should be ready to roll out this capability within the next year or two. Engaging early with vendors should prepare CIOs and IT leaders to use the benefit right away.
It will be some time before the industry has a complete end-to-end solution that electronically automates all of the steps of determining:
- Coverage
- Site of service
- Alternative therapy recommendations
- Out-of-pocket patient costs
Challenge EHR providers to quickly develop native capabilities to support data exchanges. In this way, CIOs can move the industry toward more efficient payment processes.
2. Make interoperability a priority
CIOs and IT leaders can advocate for interoperability standards. This should ease some of the challenges of data exchange that hinder checks on medical eligibility and benefits.
It feels like the progress toward interoperability is at a tipping point following recent regulation proposals by both the Office of the National Coordinator for Health IT and the Centers for Medicare and Medicaid Services.
Regardless of where those regulations land, there's going to be a dramatic shift for payers and providers. Working with third-party data and technology vendors, payers and providers will need to exchange that data in an easier and less expensive way.
CIOs can prepare by making sure their technology stacks are optimized and ready to meet the Fast Healthcare Interoperability Resources (FHIR) standards and the proposed new federal regulations.
3. Don't wait! Be proactive and prioritize today
CIOs and IT leaders can have outsized impact in the near term by focusing on individual steps in the process that are high value. CIOs don't need to wait until a fully automated process is possible. Instead, they can prioritize parts of the process that can be improved today.
They can start talking about collaboration between payers and providers. They can look for opportunities to pilot and test coverage determinations on specific medications or services. This allows providers to order out in real time and at the point of care with EHR vendors and integrated third-party tools like UHC PreCheck My Script.
Through payer-provider partnerships, health IT leaders have a unique opportunity to significantly improve care experience for patients and members.
The frustration around medical eligibility and verification of benefits is one of five key pain points highlighted in the Optum Payment Nexus interactive infographic. Explore the pain points and read about collaborative solutions for addressing each.
John Kontor, MD, serves as senior vice president of the Provider Technology Services practice within Optum Advisory Services. He leads a tech-enabled services division that helps clinical organizations drive IT strategy, optimize IT systems, and reduce system costs and administrative burden. Dr. Kontor received his Doctor of Medicine from the University of Florida in Gainesville and his Bachelor of Arts in health policy from Boston University. He practiced internal medicine for 14 years.