Availity Blog

Availity Blog

Actionable insights for medical business professionals

Following the horrific June 12, 2016, shooting at the Pulse night club in Orlando, Florida, news outlets across the country rushed to report on the events of that night and the aftermath of the tragic situation. While covering breaking news is inherently an imperfect science, multiple news agencies threw caution to the wind and erroneously reported that the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) regulations were waived following the massacre to allow family members easier access to their loved ones’ health information.

It is not an overstatement to say the healthcare industry has experienced unprecedented change since the Affordable Care Act (ACA) was passed in 2010. Healthcare has fundamentally evolved in how it is delivered and how payers are reimbursed for the care they give patients.

“Sudden” changes in the information we have and how we use it are usually not all that sudden, and it’s almost impossible to predict their effects. Whether it’s pinpoint accuracy in location data or efficient sharing of health care information, improved technology, changing attitudes about the technology, and government pressure often lead to unexpected consequences.

The American Recovery and Reinvestment Act of 2009 created an electronic health record (“EHR”) incentive program, commonly referred to as “Meaningful Use.” The program pays incentives to certain providers and hospitals to implement and make meaningful use of certified EHR technology. The three main components of Meaningful Use include: (1) the use of certified EHR technology in a “meaningful” manner; (2) the electronic exchange of health care information to improve the quality of care patients receive; and (3) the use of certified EHR technology to submit clinical quality and other measures.

As long as there’s been medical insurance claims there’s been a tug-of-war between payers and providers. Payers want clean claims and providers want to get paid promptly. Meanwhile, “dirty claims” — those with errors — are causing billions of dollars in added expenses for the healthcare industry because payers and providers have to retain extra resources to manage the rework and manual processes, among other factors. Experts agree that both payers and providers are at fault for the “calamity of claims” that exists today.

Providers submit millions of claims to payers every day. Most are adjudicated promptly and for the full contracted amount, but a fraction of these claims are denied. However, the American Medical Association (AMA) reports that between 1.38% and 5.07% of claims are denied by payers on first submission.

In two recent blog posts, we talked about the promise “Big Data” holds for risk adjustment and some of the challenges health plans face with existing systems and processes. In the final blog of this series, we look at how the Member Assessment application, part of Availity’s Revenue Program Management (RPM) solution, helped one large health plan improve the risk adjustment process.

Payers need information about the population of members in their health plans to predict and track healthcare costs, and to comply with regulatory requirements for risk adjustment and quality assessment. The latter is particularly important for members in Medicare Advantage, Medicaid managed care and Affordable Care

The administrative employees of critical access hospitals typically wear many hats. With extremely tight margins and few alternative funding sources, smaller institutions must keep staffing at a minimum to effectively manage cash flow. So, it’s not surprising when the person who checks patients in at the registration desk is the same person who handles administrative responsibilities for the emergency department.

In a recent blog post, Can “Big Data” help address the challenges of risk adjustment,” we looked at why risk adjustment is critical to the successful implementation of value-based payment models. But risk adjustment models rely on timely and accurate provider data, and many health plans don’t have the systems and processes in place to efficiently capture the right data points, relying instead on manual, labor-intensive processes. As a result, health plans face the following challenges related to organizational efficiency and provider network satisfaction.