Receiving and responding to medical record requests continues to be one of the primary contributors to lengthy claims processing delays and denials for providers. Health plans request supporting documentation, which can delay processing the pre- and post-payment review up to 45 days, on average. Technology, however, is allowing hospitals and practices the ability to efficiently and securely capture, transmit and store electronic health record information and supporting clinical data to reduce denials and reviews by payers.
Are these solutions really important for payers and providers? At present, it does not seem top of mind for payers even with CMS’ push to (finally) move toward electronic exchange of data between providers being audited by Medicare claims auditors, for example, doesn’t mean the industry – from the payer’s perspective – is moving with gazelle intensity toward the capability of doing so. The reasons are many, and understandable, of course.
Payers have bigger priorities right now with ACA, ICD-10 and other highly complex processes that require their attention. The attachment system that’s currently being used by many payers (manual delivery) works, and the thinking that “if it ain’t broke, don’t fix it” moving attachments to an electronic environment at this point may just not be important enough to these organizations to supersede everything going on at present.
But when it comes time for providers to get paid, the use of simple electronic image files can securely change the way providers get paid and grow their businesses. There are more than a billion ambulatory care visits a year producing claims in which 13 percent of those requiring attachments to support them. Each attachment averages more than three pages that the payer must review before being able to adjudicate the claim and pay the provider, according to a 2010 National Ambulatory Medical Care Survey.
For example, the annual claim denial rate in 2013 was 2.17 percent, meaning more than 70 million attachment pages were required by payers annually. Hospitals, ambulatory care centers, surgery centers, home health agencies and long-term care facilities simply experience significant improvements in their revenue cycles by using electronic attachments for their medical documentation exchange and claim processing time can be greatly reduced – in some cases by as much 60 percent.
So, why do electronic attachments matter in healthcare? Electronic document management improves processes by enabling hospitals and practices to securely capture, transmit and store supporting documentation for medical review. They are secure and HIPAA-compliant for document transfer, require minimal time and training to implement and essentially offer integrated services with some hospital information systems.
The value proposition is simple for health systems, including increased productivity (less phone time spent tracking status of mailed or faxed claims); fewer denials; faster payment; detailed tracking reports; records of every employee who viewed the attachment; and real-time follow-up on claims with attachments.
The solutions allow providers the ability to transmit both solicited and unsolicited documents via an information exchange to all participating health plans. The claim attachments are then able to be viewed and acted upon in a timely manner. According to the American Medical Association, automating the claims process can cut costs, helping organizations save thousands a year while relieving staff members of some of their most tedious and time-consuming tasks. Additionally, automating the claims submission process can:
- Minimize claim rejections and resubmissions
- Deliver claims to health insurers in real time
- Expedite payer responses and boost cash flow
- Free up time for other revenue-enhancing tasks
- Reduce claims submission costs
An evidence of savings realized can be seen as published by Milliman from 2006. For example, the cost to submit manual claims is $6.63 x 6,200 (6,200 is based on an average of claims submitted for a single physician) equals $41,106 per year. Compare that to the cost to submit electronic claims, which is $2.90 per claim x 6,200 = $17,980. Thus, the average annual savings per physician from automating claims submission: ≈$23,126.
However, even with a cost-savings of more than $23,000, practices saving money may not be the most important factor of the solutions. Security and safe transfer of the information to payers is the priority of all practices, and is possible. Also, the money saved may not mean as much as the efficiencies created or the comfort and reliability of being able to track, monitor and follow claims and attachments throughout the adjudication process.
Additionally, the solutions create a sense of interoperability, a concept much hyped but often difficult to achieve and often lagging in other areas of the hospital or practice. With electronic attachment solutions, information can easily be transferred across multiple systems securely and efficiently, with little effort and implementation time.
HIPAA-compliant data transfer
Even with these benefits, often overlooked is that the technology exists for HIPAA-compliant transfer of electronic data, allowing for information exchange between providers, payers and clearinghouses. Even with the oft discussed lack of exchange capabilities with current solutions, such as between competing electronic health record systems, hospitals and health systems can simply deposit required information into a secure electronic envelope to support the clinical coding on a claim, which can then be easily transmitted to a payer. Though not an exchange of data in the “traditional” sense – between electronic health record and electronic health record, for example – it is possible for hospitals to use their technology and systems to communicate with outside parties, such as payers (including CMS for Medicare/Medicaid,) clearinghouses, and other practices.
In relation to electronic attachments, with a few simple keystrokes, providers can simply upload or capture requested documents whereby a unique tracking number is then assigned to the claim, and it gets transmitted securely to the payer. Once the third party receives the claim, examiners then have the ability to view the supporting documentation. Not only is the data transferable, but the attachment is stored in a secure repository and is accessible to designated payers and providers. Attachments sent by providers can include a number of components, such as adverse drug reaction information, lab and operative reports, ER records, certificates of medical necessity and any other documentation required by a payer to adjudicate a claim. Attachments can be sent along with the initial claim submission (unsolicited) or in response to a request for additional information (solicited).
How the technology is changing healthcare
The technology is changing healthcare in a number of ways. In the near term, organizations will be able to continue achieving clinical and financial excellence as health information becomes more fluid and mobile.
Additionally, automating manual processes makes routine tasks more efficient. Clinical excellence furthered by the use of EHR and other technologies will continue to facilitate the ability for practitioners worldwide to share patient information to enable them to treat patients more efficiently. Additionally, automating billing, claims and attachment processes will reduce lengthy reimbursement periods from payers and reduce unnecessary costs associated with the redundancies in healthcare administrative processes (i.e. refilling claims/documents, manually tracking reimbursements, etc.)
Certain electronic solutions enable providers to electronically respond to RAC, MAC, CERT and ZPIC audits given certain guidelines, for example, by being able to connect through Medicare’s esMD program. The esMD program was launched by CMS to provide an electronic mechanism for providers to respond to audits. Because of these electronic solutions, responding to audits is much quicker, more secure and easier with this technology than when using traditional paper methods to manage the same process.
Additionally, with the technology, providers can import documents using a variety of acquisition methods including scanning, screen capture, file import and print capture. When used to defend against audits, these solutions typically help those in healthcare eliminate faxed or mailed audit responses, ensure timely and confirmed responses, reduce postage and fax charges, decrease administrative time spent copying, eliminate lost submissions and provide HIPAA-secure transmission and storage of files.
The benefit to providers and to health systems is clear, especially in the age of the “wireless” office. With the push toward EHRs, electronic transfer of health information and seamless interoperability, these technologies go hand-in-hand with those developments. Specifically, in regard to this case, the technology can improve acceptance rates for claims requiring supporting documentation, as well as decrease days claims spend in A/R; reduce occurrences of pended and denied claims; eliminate lost attachments; reduce postage and fax charges; eliminate paper-based claims, appeals and audit processes; improve office staff productivity and overall billing efficiency; and provide secure HIPAA-compliant transmission and storage.
All of this supports a more efficient and profitable health system driven by technology. Secure electronic claim attachments improve outdated processes with little intrusion and minimal investment – something many of healthcare’s other IT solutions can’t claim.