Availity Blog

Availity Blog

Actionable insights for medical business professionals

The General Data Protection Regulation (GDPR) governs the privacy and security of personal data collected from the European market, effective May, 2018. Outside of the European Union (EU) and the European Economic Area (EEA), it only applies to those processing personal data of EU/EEA subjects for the purposes of offering goods or services or monitoring subjects’ behavior in the EU/EEA, but the law has had a major impact worldwide. While the primary objective of GDPR is to increase the protection and privacy of individuals’ data, it has produced a host of unintended privacy consequences, including its effect on ICANN and the WHOIS database.

Consumers with health insurance, both independent and employer sponsored, rely on insurers’ provider directories to make choices about their plans and find physicians that are right for them. Directories include vital information such as essential contact details, distance from public transportation, accessibility for individuals with disabilities, languages spoken by practitioners and staff members, and more.

The healthcare industry still has a big paper problem. According to one report, faxes account for almost 75 percent of all medical communication.

Health plans are committed to reducing waste and inefficiency, but the healthcare industry as a whole still spends too much time and money manually managing administrative transactions. One report found that faxes account for almost 75 percent of all medical communication, and the 2017 CAQH report predicted administrative costs would reach $315 billion by the end of the year. These costs are driven largely by the continued reliance on phone calls, fax, and mail to manage claims transactions.

Claim submissions are the most common electronic transactions in healthcare, edging out even eligibility and benefits checks, which are often still performed by phone. It’s clear that submitting claims electronically leads to faster payments and fewer denials, at less cost to providers and payers, however six percent of claims are still submitted via paper.

Countless businesses and healthcare organizations miss out on their portion of available settlement proceeds each year. On average, only about 20% of eligible entities collect their share of any given settlement fund. In many cases, the proceeds represent a significant amount that is added right to your bottom line. While settlements vary, one constant is that a claim must be submitted in order to collect any money. This is where a Settlement Recovery Service can help.

CMS’s recent report on the state of provider directories identified three challenges facing health plans. Recent blogs covered the first two challenges: the issue of contractual versus resource constraints and the lack of internal audits by health plans to verify provider information. A third problem creating directory inaccuracies is that health plans rely on providers to reach out and tell them when information changes. From the report: “MAOs cannot assume that they will be informed when a change in provider location occurs; instead, MAOs need to implement routine processes that drive more accurate information reflected in their directories.”

The second problem CMS identified in its report on provider directories was a lack of internal audits by health plans to verify provider information. The report faulted health plans for outsourcing the audit process, stating “Medicare Advantage Organizations (MAOs) placed full faith in credentialing services and vendor support, and even in provider responses...” and “if MAOs had implemented routine oversight of their processes for data validation, errors in the provider directory would have become apparent.”

The RISE conference in Nashville was a great opportunity to learn about new approaches to analytics and member engagement, as well as to hear about many of the creative initiatives health plans are implementing to improve quality scores and meet the complex web of risk adjustment requirements for Medicare Advantage, ACA, and Medicaid.

What’s the current state of payer-provider collaboration, and what does the future hold? Big questions to be sure, but we tried to find answers during a recent Availity-sponsored SmartBrief webinar featuring healthcare industry expert Jay Eisenstock of JE Consulting.