Member Spotlight

Q and A with Miriam Paramore, Chair of HIMSS’ Financial Systems Steering Committee

Miriam J. Paramore is the senior vice president of Corporate Strategy at Emdeon Business Services, a leading provider of revenue cycle management and clinical communication solutions. Previously, Ms. Paramore was a partner with Commonwealth Leverage, a business development and investment company focused on health information technology, eHealth and healthcare services.

A nationally known expert in the business of healthcare and health information technology, Ms. Paramore is an Advisory Member of HIMSS’ Board of Directors and a member of CareSource Management Group’s Board of Directors. In addition, she is the immediate past chair of the Louisville Health Information Exchange and a member of the eHealth Advisory Committee for the Commonwealth of Kentucky.

1. What is the significance of HIMSS growing its work within the financial systems area of healthcare?

In helping to transform healthcare through IT, it is important for HIMSS to have a voice in both the clinical and financial sides of the industry.  The healthcare revenue cycle is an extremely complex and broken process, one that is ripe for transformation.  If we hope to drive price transparency and other key national initiatives, we must have competence in the financial systems and business systems areas.

2. How can IT be leveraged with quality reporting and pricing data, so that stakeholders, for example, can easily access information on quality outcomes online?  

Because of the limited availability of clinical data, and the lack of standards in real use today, it is very difficult to get a picture of healthcare quality.  Some quality information can be extrapolated from claims data, but it is imperfect.  Still, it is best to start somewhere. 

3. What work is being achieved through collaborative efforts between HIMSS' Financial Systems Steering Committee and its Patient Safety & Quality Outcomes Steering Committee? 

These two groups are looking for ways to link up and marry the available clinical and financial data in hopes of creating a comprehensive data set for analytics to drive quality/cost initiatives.

Click here for more information on HIMSS' Financial Systems Steering Committee.

Call for Participation: Financial Edge

Share your feedback on this first issue of Financial Edge. Let us know what you’d like to see in future issues and if you’d like to participate in planning and developing newsletter content.  Contact Pam Matthews, CPHIMS, HIMSS Senior Director, Healthcare Information Systems or Nancy Vitucci, HIMSS Manager, Publications.

 

 

---

Clearinghouse 101

by Dave Cheli

Healthcare clearinghouses often seem to be overlooked in many healthcare IT conversations as well as RHIO and HIE discussions. This is understandable given that their function in the healthcare industry is that of the “silent cloud” where all the electronic data interchange “magically” takes place. Fortunately for the healthcare industry, the current infrastructure is highly developed and used daily by the large majority of healthcare participants.

To those unfamiliar with healthcare clearinghouses, these electronic data interchange (EDI) entities have been around for about 30 years and are regulated under HIPAA.

The EDI companies connect to form the “cloud” and provide an array of services including both basic EDI and various value-added services for their customers. At the core, however, is the secure exchange of sensitive electronic data. This data is sent into the “cloud” in various formats and methods and is subjected to various format transformations and numerous data edits in order to be delivered to the appropriate end-point in the format required by that entity. This greatly simplifies the electronic data exchange process for healthcare entities. They need not worry about how to send or receive data from numerous start and end points or how to support multiple formats. To date, millions of transactions are passed through this “cloud” on a daily basis, consisting of all possible transaction types: financial, administrative and clinical.

One last point worth noting: the clearinghouse world has an accrediting body, the Electronic Healthcare Network Accreditation Commission or EHNAC. This commission has developed extensive criteria from best practices that are used to assess an organization’s health and effectiveness. The criteria cover the following areas: customer service, operational and marketing activities and HIPAA privacy and security. EHNAC accreditation assures customers they will receive a minimum standard of service and performance. 

Clearinghouses are well positioned to continue evolving to meet future needs of the industry and provide a firm foundation on which any HIE initiative can be built.

Dave Cheli is the Chief Information Officer at Gateway EDI and a member of HIMSS’ Financial Systems Education Task Force.

^ back to top

Viewpoint: Real Time Claims Adjudication – Fact or Fiction?

With real time claims adjudication (RTCA), providers bill for service at the time of service. Before the patient leaves the office, the provider submits a claim and receives a fully adjudicated response back from the payor.  Total and allowable charges, as well as the patient's responsibility, are noted, so providers can collect the appropriate payment before the patient leaves the office or set up a payment plan.

Is RTCA feasible in today’s healthcare environment?  Will it easily integrate with a provider’s current practice management system?  Are providers’ offices ready to handle this new technology?  Is RTCA the answer to reducing bad debt and cutting administrative hassles?

We posed the question, “Real Time Claims Adjudication – Fact or Fiction? ” to a few of our industry stakeholders. Here is what they are saying:

Real Time Adjudication: Simplifying Healthcare
Adoption of real time claim adjudication (RTCA) is slow, but it’s happening.  The biggest hurdle is the change to a retail-oriented “check-out” workflow for physicians’ offices.  The status-quo—batch processing—has been around too long to change overnight.  The healthcare industry must ramp-up collaboration across payors and standards organizations to make the transition to real-time easier for physician office staff. 

First, the industry needs to settle on a transaction standard for RTCA.  Unified standards will allow vendors to build RTCA-enabled systems without the risk of investing in throwaway code.  Standards also pave the way for other payors to build RTCA.  All healthcare constituents must simplify administrative processes for care providers; to do so, we must work together to reach the same goal.

RTCA is available today and there are indeed physicians taking advantage of its value.  But if we establish standards that enable more widespread implementation, we’ll see claims processed in real time in droves.

—Michael J. Baker, Director of Product Support, UnitedHealth Group IT

Although the benefits of real-time claiming are indisputable, the healthcare industry has shown hesitation in adopting a real-time claiming model.

Real time claim adjudication (RTCA) is necessary to move the healthcare industry closer to price transparency and optimal efficiency. Growing participation in consumer-driven health plans has resulted in increases to providers’ bad-debt and patients’ uncertainty about their out-of-pocket responsibility.

Work efforts and tools are emerging in the industry focused on facilitating provider access of critical data required to effectively move to RTCA. Enabling providers to collect or set-up payment arrangements and empowering patients with information to manage their own healthcare treatment and cost are bridging the gap for payors and providers not yet able to support a real-time claiming solution.

—Emdeon Business Services

Real-time Claims Adjudication: A Long Way to Go
Real-time claims adjudication remains a vision of the future for the healthcare industry—and could remain so until the next decade.  A major reason is that a precursor to adoption is the migration to the presumed next version of the HIPAA EDI transactions (5010), which may not occur until 2014.*

Another is that the processes and technologies hospitals use today to gather charges may need to be re-thought.  To be able to quickly determine, collect and process charges for “real-time” billing may mean changes to long-standing processes.  Instead of today’s model with individual charges that take time to accumulate, will the future hold a “package” pricing model that would be more conducive to real-time submission and adjudication?  Real-time adjudication implies providers can gather and submit charges to insurers when services are rendered, enabling them to collect the patient’s portion at the point of care. That isn’t the case today.

— John Hawkins, Senior Product Manager and Joseph R. Thear Jr., Vice President, Product Management, QuadraMed

*An article on the impact of implementing (and preparing to implement) the 5010 version of HIPAA will be featured in the July 08 Financial Edge.

The capability of producing real-time claims transactions is available now; it can and, in fact, already has been done. The industry seems to be moving toward more real-time claims processing.  It is just a matter of time before most organizations can send, receive and respond to them.

Eligibility and claim status transactions appear to be the most prominently used real-time transactions. This may be due to the minimal amount of information required by most payor organizations to generate a response compared to the amount of information that is required for a claim to be processed.

I don’t think the value of real-time claims transactions can be realized until real-time adjudication becomes more prominent. The trend seems to be more applicable to physicians and/or professional services.  Many payor organizations offer tools for real-time adjudication for these types of claims but not for hospital or institutional claims. Until healthcare providers can receive real-time adjudication for the bulk of their claims or at least for their larger payors, they will be reluctant to change existing processes or run multiple processes that may be required for real-time claims transactions.

—Lori Brocato, RCM Product Manager, HealthPort

Enhanced Batch Processing Is Interim Step to Realizing RTCA
RTCA is the future.  Upgrading current batch processing is a first step and an elemental change to ensure successful transition to RTCA.

Increasingly, health plans are offering high deductible plans, fueling demand for RTCA and challenging providers to improve front-end collections and facilitate pricing transparency, determining payment at the point of service for patient and payor. Though the industry lacks a regulatory push for adoption, there are changes in workflow and behavior which providers must adopt to facilitate RTCA.  Providers must rethink office workflow models, submitting claims often, and software vendors must reprogram workflow to accommodate RTCA requirements.

Until industry standardization and workflow redesigns are realized, providers should realign office processes to expedite batch processing.  For example, claims are submitted to a payor who accepts claims at the time of provider submission, as many payors accept claims multiple times a day. Instituting improved batch processing speeds revenue regardless of time submitted, reducing AR days and netting faster reimbursement.

— Lisa Williams, Product Director, RelayHealth

Perot Systems proposes Real Time Claims Administration (RTCA) is in fact…FACT! While in limited operation today, a driving force of the future is to seamlessly connect healthcare constituents: payors, providers, (physicians and health systems) and members.

With RTCA, immediate eligibility verification and claim adjudication can occur at the point of sale, which will lower administration costs to providers and health plans, improve revenue cycle management, and provide immediate and current patient liabilities.

With industry trends continuing towards Consumerism, accurate patient liabilities are critical to properly administer accounts linked to a member’s health coverage. FSA, HRA, and HSA liabilities can now be determined, as well as paid, at the point of sale.

RTCA is not only a fact and being utilized by a few progressive companies, it remains the driving force in the synergetic future of an efficient continuum of care.

— Mike Ragan - Vice President Payor and Physician Sales, Perot Systems

We would like to hear from you (especially stakeholders from the provider side—hospitals and physicians’ practices).  Please submit your view on RTCA to Nancy Vitucci, HIMSS Manager, Publications.

^ back to top

HIMSS News:
Call for Nominations for Board and Nominating Committee

Nominations are now being accepted for positions on the HIMSS Board of Directors and the Nominating Committee.  Nominees must be a Regular or Life Member or the senior executive representative of an Organizational Member who have achieved and maintained advanced membership status. Please send all nominations to:

H. Stephen Lieber, President/CEO
HIMSS
230 East Ohio Street, Suite 500
Chicago, IL 60611-3269
executive@himss.org

Nominations must be received by Aug. 1.

*To obtain further information on the advancement process and/or access the application, go to www.himss.org/advancement.

^ back to top

 

The inclusion of an organization name, product or service in this publication should not be construed as a HIMSS endorsement of such organization, product or service, nor is the failure to include an organization name, product or service to be construed as disapproval.

Financial Edge is a monthly online newsletter published by the Healthcare Information and Management Systems Society (HIMSS).

Copyright© 2008 by the Healthcare Information and Management Systems Society.
All rights reserved. No part of this publication may be reproduced, stored in a retrieval system or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without prior written permission. Contact HIMSS Publications at 230 E. Ohio St., Suite 500, Chicago, IL 60611; 312-915-9238; nvitucci@himss.org

HIMSS Healthcare Information Systems Initiative
Patricia Wise, RN, MSN, MA
Colonel, USA Ret'd
Vice President, Healthcare Information Systems, HIMSS
For information on HIMSS’ Financial Systems Initiative
Pam Matthews, CPHIMS
Senior Director, Healthcare Information Systems, HIMSS
pmatthews@himss.org/706-838-0583
For information on Financial Edge
Nancy Vitucci
Manager, Publications, HIMSS
nvitucci@himss.org/312-915-9238