When it comes time for healthcare providers to get paid, forget complex algorithms and cutting edge reporting systems. It’s the lowly JPEG—yes, the common PC image file format—that’s bringing home the bacon.
So much of the sizzle of healthcare information technology seems like a tour of the bridge of the starship Enterprise, or perhaps a quick sprint through Starfleet engineering.
Sophisticated analytical algorithms tease out hidden provider or patient behaviors. Google Glass offers up in-clinic encounter hints and notes. Increasingly miniaturized mobile technology tracks “quantified selfers” who expect up-to-the-minute telemetry on what’s ailing them.
But when it comes time for providers to get paid, the lowly JPEG, a common PC image file format, is bringing home the bacon.
According to the 2010 National Ambulatory Medical Care Survey, more than a billion ambulatory care visits per year produce claims or encounters with 13 percent requiring attachments, each of which averages 3.2 pages in length, before the payer could adjudicate the claim and pay the provider.
The annual claim denial rate in 2013 was 2.17 percent. That translates to managing more than 70 million attachment pages annually, as providers try to get paid by submitting (or resubmitting) appropriate documentation.
Boca Raton Regional Hospital, with 400 beds, is probably pretty typical when it comes to striving to get its claims paid. Rudy Braccili, Jr. is executive director of revenue cycle management and a previous leader of Tenet Healthcare’s National Medicare and Medicaid Center in Florida.
If Medicare had a ground zero for patients, Florida would be it. Boca Raton’s payer mix ranges from 65 to 75 percent Medicare.
“The hospital industry has been steadily moving toward replacing paper submissions of all administrative type paperwork from paper to electronic,” Braccili tells me. “The industry’s been moving in that direction for 15 years, slowly, and arguably slower than most other industries.” A few years back, submission of claims to payers went electronic; payments, a.k.a. remittance advice, also went electronic.
But where payers take issue with what’s been submitted by a provider, and request additional documentation, technology lags behind in too many places.
“There has not been an electronic solution,” Braccili says. Too often, providers’ claims submitters have had to locate appropriate electronic patient medical records, print them out, then mail or fax them to payers.
The medical records themselves may now be electronic, but when you print it all out, including documentation by physicians, nurses, pharmacists, nutritionists and physical therapists, it’s blizzard conditions. There are boxes and boxes of dead trees clogging mail rooms even in hospitals with bright, shiny new EHRs running on clinicians’ desktops.
What’s more, once a communication leaves a provider’s IT system and enters the mailroom of provider and payer alike, too often the opportunity exists for the documentation to go astray.
Even if that doesn’t give you the HIPAA willies, think about how it slows down the provider revenue cycle. When providers can send this documentation electronically, payers can no longer plausibly deny they ever received such documentation.
Enter the JPEG
In 2011, after giving a presentation, Braccili was approach by a representative of MEA, short for Medical Electronic Attachments, a clearinghouse for scanning the needed attachments, such as before-and-after pictures of a hip replacement—documentation that can get a claim paid. MEA takes care of getting the attachments to payers, and confirms back to payers such as Boca Raton that they were received.
MEA had just submitted a request to CMS to become a certifiedHealth Information Handler (HIH), a group with which CMS was preparing to pilot Electronic Submission of Medical Documentation (ESMD). MEA became one of an initial dozen HIHs, and remains the second largest of the two dozen currently registered, according to Lindy Benton, CEO of MEA.
“We had been waiting and wanting electronic medical record submissions to Medicare for years,” Braccili says, shuddering at the thoughts of RAC audits he’s known. “It’s awful without it. We couldn’t say yes fast enough.”
Two years ago this August, Boca Raton submitted its first medical record to its Medicare Administrative Contractor, First Coast Solutions of Jacksonville, Florida. Because MEA’s service is not yet entirely cloud-based because of security precautions, Boca Raton had to download a small program to its medical record professionals’ PCs in order to run the service.
“The install was done 95 percent without the involvement of our IT department, which is extraordinary for any kind of implementation that I’ve ever witnessed in my career,” Braccili says.
Medical records professionals access Boca Raton’s previously installed in-house electronic repository, find the specific documents they need to send, and create JPEG files, which MEA then grabs and allows to be transmitted to Medicare with a single click. Confirmation of receipt arrives back from Medicare the next day.
The new business process moved the hospital from a claim denial rate of 40 percent to zero, and has saved the hospital a cool half million.
By the way, the next time payers want to impress you with their advanced analytics, ask them why payers have no nationally adopted standards for submission and receipt of these claims-related attachments, necessitating the creation of companies such as MEA to solve the problem.
Are mailrooms at the trailing edge everywhere? “Payers are in the business to make money off the float,” Braccili suggests.
But with just enough technology, they will be making a little less, and putting money back in the pockets of providers more quickly.