Healthcare’s Fumbling Over Electronic Records. Or Should They Just Re-Think It?

Think about it. Phones. Faxes. Even email.

A bit rusty, no?

No. This is 2018 healthcare, when it comes to physician offices  handling administrative and insurance claims transactions.

A non-profit healthcare alliance last month found in a significant study that healthcare is losing a big opportunity to save billions of dollars by its failure to switch over fully to electronic claims- related business processes among providers and insurers. The business of healthcare in the U.S. can and should be simpler, less burdensome, and, yes, perhaps most of all, less costly. And it’s not happening.

The CAQH a non-profit Washington, DC-based alliance of health plans and trade associations, uses words like “modest progress” in the transition from manual to fully electronic administrative transactions, but also  “backward,” and “no longer sufficient.” The organization also has been known as the Council for Affordable Healhcare Quality Inc.

“There are billions of dollars at stake. The electronic transactions should be more efficient and accurate and less of an administrative burden,” says Reid Kiser, interim director, CAQH Explorations, and lead researcher for the report. “They support optimized workflows for providers and the focus on the patient that health plans want to deliver and allow them to drive toward population health,” Kiser says. Kiser is an independent consultant with Kiser Healthcare Solutions, LLC.

Physician use of electronic inquiries rose by  6 percentage points for inquiries related to claim status, and 3 percentage points for eligibility and verification inquiries in 2016 compared to the previous year, according to  CAQH, which works to share initiatives to streamline costs and improve the business of healthcare. Its CAQH Index was released in June.  (In its study, CAQH also reviewed dental practices).

At a time they are trying to serve more of their patients, providers are spending up to 30 minutes on manual tasks, like making phone calls, sending faxes – faxes! – and mailing correspondence. Thirty minutes may not seem like much, but when you have only so minutes in a doctor’s office, that means a lot.

That’s a problem, Kiser says. “Once (patients) move over to a new health plan that information is essentially lost if (a patient) comes back to the health plan a few years later. From the (CAQH) perspective, it’s manual work that the provider has to do,” he says.

Beyond adoption levels, the index estimates the cost and time associated with conducting administrative transactions. On average, each manual transaction costs the industry $4.40 more than each electronic transaction and requires five more minutes of provider time.

Think of how many we’re talking about: The annual volume of administrative transactions reported by medical plans increased substantially, rising by 25 percent, from 4.8 billion in the prior year to more than 6 billion.

Going in Reverse: Or Not?

Whatever gains have been made in recent years are actually going backwards in the world of automation of claims related to business transactions. The savings potential from automating clams management increased to $11.1 billion annually in the most recent CAQH Index, with the focus on more than $7.5  billion for medical providers and $2 billion for dental providers and the remaining $1.7 billion for health plans.

That is an increase over $1.8 billion in potential savings from the previous year. The index is described as the industry source for tracking health plan and healthcare provider adoption of electronic administrative transactions for both medical and dental care.

Portals: “Accelerate or Hinder Progress?””

There’s a lot of data here, and CAQH points to one of the possible problems in evaluating the use of full electronic records, and that’s portals, the secure online websites that allows insurers, providers and patients get more involved in care.  While they are certainly helpful,  each one involves  a serious amount of work for physicians, including paper-pushing, such as clinical paperwork needed to support claims.  So it’s seen as being partially electronic in the CAQH Index and that raises all kinds of questions, including: is portal use really a bridge toward better use of electronic record use, does it hold it back: is it advancing, or not?

While the report says portals offer health plans a “highly automated solution,” some provider groups indicate that portals also create “substantial administrative burdens.”

“This is because portals require the provider to sign on and navigate a different online system for each health plan with which the provider is contracted,” the report says. “Also, portals lack advanced features common to clearinghouses and clearinghouse-integrated practice management systems, such as the ability to validate claims and check eligibility and benefits prior to patient appointments.”

That effect,  says CAQH: “may accelerate or hinder progress.”

So is the use of portals for physicians and dentists actually hurting them in using overall electronic records?

“We’re not at that point of our research to clearly understand that,” Kiser says. “Are we getting to fully electronic or are we at the point in the market just accepting all of these partially electronic, or portal transaction?”

Reid Kiser

Reid Kiser, lead researcher for CAQH report

An estimated 925 million manual transactions and nearly 14 billion electronic transactions were conducted by medical plans, a 38 percent increase over the prior year.

This is because a much higher number of administrative transactions were conducted using costlier manual transactions. This includes the portal transactions.

One study estimate with costs associated with healthcare billing and insurance-related administrative activities to reach $315 billion by this year, nearly as much as the 10 highest spending state Medicaid programs paid combined in 2016 to provide care for more than 46 million beneficiaries.

In a call to action, the CAQH Index concludes that the “ the relatively slow, incremental process reported in recent years of the transition from manual to electronic administrative transactions is no longer sufficient.”

It proposes that “industry participants strongly support provider access to robust electronic data interchange systems and expand the understanding for reasons behind increasing portal use, and urges all stakeholders to embrace the transition to fully electronic transactions.”

The research concluded that few vendors support all of the most essential electronic administrative transactions.

Adjustments Needed?

“We’ve seen tremendous cost and time savings from our investment in technology,” said Jody Meza, practice administer, Alpine Medical Group LLC in a statement. “We feel it’s important to do everything we can to deliver care as efficiently as possible for our patients, and automation of our administrative transactions is one way that we deliver on that goal.” — Joe Cantlupe

Note: The 2017 CAQH Index is the fifth annual report assessing industry progress to reduce the use of manual transactions and eliminate cost. Data was submitted from health plans covering more than half of the commercially insured U.S. population in the year studied based on enrollment reported in “AIS’s Directory of Health Plans: 2017.” Medical health plans contributing data covered 155 million lives, or approximately 51 percent of U.S.

It represents collaboration between healthcare providers and health plans. The report reflects data from participating health plans representing 112 million enrollees – almost 45 percent of the privately insured U.S. population – on more than four billion transactions. A range of healthcare facilities and provider practices participated in a day collection process conducted on behalf of CAQH by Milliman Inc.

CAQH Report’s Data:

  • Claim submission had the highest overall adoption level among the electronic transactions studied, at 95 percent – a 1 percentage point increase over the prior year.
  • Fully electronic coordination of benefits/crossover claim transactions increased 19 percentage points to reach 75 percent.
  • Fully electronic eligibility and benefit verifications increased 3 percent over the previous year, reaching 79 percent.
  • Fully electronic claim status inquiries rose 6 percentage points, from 63 percent the previous years to 69 percent. The volume of phone inquiries and the concurrent need for manual labor remained stable.
  • Claim attachment, with a fully electronic adoption level at 6 percent, showed no measurable change as compared to the previous year.
  • Electronic funds transfer adoption for claim payment decreased slightly, falling to 60 percent from 62 percent the previous year.
  • Fully electronic remittance advice transactions increased slightly, increasing to 56 percent, one percentage point over the previous year.
  • Fully electronic remittance advice transactions increased slightly in the 2017 index, rising to 56 percent, one percentage point over the previous year.
  • Fully electronic prior authorization transactions declined by 11 percentage points.
  • Use of partially electronic transactions rose by 10 percentage points.






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