Exploring opportunities to improve provider-payer data exchange
The last thing a patient needs when they receive a troubling diagnosis is to be asked to navigate a complex administrative process to receive their care. The COVID-19 pandemic has highlighted the importance of providing a seamless patient-centered experience that addresses increasing expectations, technology advancements and consumer transparency.
It may often seem like providers and payers are on opposite sides of the fence, but they are serving the same customer – the patient and beneficiary. Making data exchange work seamlessly in the revenue cycle space benefits all concerned. In this roundtable, sponsored by Cerner, revenue cycle leaders share strategies for effective data exchange between providers and payers, and weigh in on the benefits and challenges.
Shawn Stack: What are your organization’s goals regarding emerging technologies and/or regulations that connect payers and providers more deeply?
Jana Danielson: At Nebraska Medicine, we have been working with our payers to help us with automating processes such as authorizations, making sure
that our payers can communicate with us via electronic methods. For example, we are working with Blue Cross of Nebraska to expedite submission of records. Blue Cross is one example, but there are others that are much further along. It’s really a partnership since it benefits us both in the end.
Stack: When you speak to those payers and start the conversation, do you find that they prefer one vendor that does electronic notifications over another?
Danielson: We have not experienced that up to this point. I think they’re pretty open. Utilization management for continued stays is where not everybody from the payer side is sitting in the same place.
Sue Martin: I know Blue Cross in Kansas City is doing a lot of work right now to make sure patients have a much better experience. Have payers been trying to provide more information, whether it’s in regard to claims or insurance benefits and so on, to reduce denials upfront in any of your areas?
Danielson: We have been implementing processes to prevent denials from happening and impacting our patient and their beneficiary – there has been some work with various payers to really work through some of those issues. They don’t want to look bad with their beneficiaries.
With our bigger payers, we have routine conversations around those types of situations, and we provide them with feedback. It could be that they need some education on their customer service side. We’ve also identified claims processing issues that they need to correct. But sometimes it’s something on our end that needs to be fixed. It’s important to have those open conversations and to keep the patient at the heart of the conversation.
Ethel Hoffman: What I see is a high degree of variability from market to market. Currently, I am working with a client in southeastern Pennsylvania, and in that market in general, the payers seem to be very immature in terms of initiatives and resources put toward technology and advancements. In other parts of the country, particularly in the West Coast, they are much more advanced. In my experience, the differences are not necessarily urban versus rural, but regional. But COVID has slowed down some of these kinds of activities because so many people are working remotely, limiting their ability to come together and have these meaningful conversations and be more innovative.
Mike Blair: Sometimes we forget that it’s really about the patient. Healthcare can be really confusing for them to navigate, especially for an individual who rarely engages with a health system. Expecting those patients to navigate between the health systems and health insurance companies is really unfair to the to the patients, and we need to do as much as we can to make that seamless.
Amy Assenmacher: Here at Spectrum Health, we have the benefit of being a part of an integrated delivery system. Our vision is to deliver personalized care – simple, affordable and exceptional. And I think that ‘simple’ is an important priority that we put at the forefront when we think about automation and what are we trying to solve. Amazon and other companies have defined expectations for consumers, which was amplified, especially during the COVID pandemic, reinforcing the need to be one step ahead in making it easier on the patient. How can we reduce the administrative burden for payers and providers while eliminating extra steps for the patient? We have direct conversations with payers challenging the back and forth with denials and appeals when it is clearly painful for everyone.
Stack: What do you think are the most important and impactful payer-provider data-sharing use cases for revenue cycle management?
Danielson: We make sure that we share with the payers time-to-pay, accuracy of payment, incorrect information in denials and patient concerns that come in through our customer service. We let them know if we would like to have a discussion to expedite processes and improve accuracy. Timeliness and quality are both important to really make things work, and hopefully someday we can start to auto-adjudicate at discharge. We also give them anonymized feedback about how they compare to other payers.
Ashley Allers: We are very close to being able to adjudicate upfront if we could get payers on board with that. Most of our data is there, right after the clinician completes everything, so getting the payers on board with that clinically driven revenue cycle and adjudicating quicker, I think, would make everyone’s relationships work better.
Danielson: We’re easily able to capture working DRGs (diagnosis related groups), if nothing else. And it will be interesting to see how much progress we can make in the next three to five years to do things in a more-timely fashion.
Martin: Some payers have forged ahead with total care plans, where authorization is done upfront and you don’t have to keep going back for additional approvals. It looks like it’s going to be a game-changer. Have any of the payers moved forward with you yet?
Hoffman: I have seen early work around that in some markets, mostly on the West Coast. I think COVID has slowed down some of the activity, but it’s starting to pick back up. The ability to be successful with that is, in a big way, dependent on how fine-tuned your revenue cycle functions are, and I think that’s where a lot of the variability comes in, not only on the plan side, but on the provider side. Not all of the provider organizations have the resources or the processes in place to handle those functions well to begin with, so it’s more of an uphill battle. You have to first clean house to get to that point where the payer has confidence with this approach.
Blair: If as a health system you’re performing at a level that indicates you’re providing good care – you are not doing procedures that don’t need to be done – does it really add any value by requiring a prior authorization on every single service or drug? Or should we accept that this organization operates at a certain level and just streamline the process, with some type of lookback or annual review? Don’t treat every system exactly the same. At M Health Fairview, where I previously worked, we have the fourth-best lung transplant program in the country, yet every transplant was scrutinized, not because of the care that was provided, but because of the high cost of transplants.
Danielson: It would great if between providers and payers, we could get to the point where it’s understood that there are certain rankings or clinical data that demonstrate that the care being provided is exceptional and could waive some of the prior authorization requirements.
Stack: What future opportunities do you see for payer-provider data exchange? Would the creation of standards encourage or discourage solutions in these areas?
Danielson: Record reviews take place, but there is not necessarily an electronic method to say, “Here’s where we disagree.” There are still a lot of verbal conversations or else one person making decisions, instead of looking at it from a global perspective.
Assenmacher: I’d go back to the concept of scorecards for payers to define and standardize key metrics that both the provider and payer should keep an eye on. An industrywide scorecard would give us a common language for assessing the efficiency and operational impact of authorizations, denials, appeals and audits. Getting to common definitions around some of those metrics will help us to identify solutions to the hurdles we have been discussing. A blinded scorecard can show who are the high-value payers, and how they compare and where there are opportunities to improve.
Stack: Are you submitting your medical records electronically to most payers now?
Allers: We definitely have gotten a good start on it, unfortunately we are not always able to submit them electronically.
Wendy Apland: Here in Oregon, we have a Coordinated Care Organization (CCO) structure for the Medicaid population, and each county in the state is assigned a CCO by the Oregon Health Authority. Data is submitted electronically, and the CCO reports on how each organization is performing compared to the contract terms as well as quality measures. My facility went non-contracted out-of-network with our area CCO because we had problems with inaccuracies in data reporting. I had to complete filings with the Oregon Health Authority explaining why we were going non-contracted for the hospital facility. The coordinated care plans are being managed very differently from county-to-county and other areas are not experiencing those issues. We decided to try this non-contracted approach for a year, and if data reporting improves, of course, the CCO contract would be an option to consider in the future.
Stack: Do you have multiple suppliers solving for your payer-provider data sharing goals? If so, how do you navigate a diverse vendor ecosystem?
Assenmacher: You have to study the different vendors and figure out which portfolios fit best for your organization. We have some guiding principles when we choose suppliers to partner with: We are looking for vendors focused on high-quality, lower-cost, improved patient experience and streamlined processes. We’ve seen an aggregation of companies that acquire different functions and features that fill this void in the market. Real-time auth, real-time eligibility, claim statusing – all those things that streamline interactions between the payer and provider – have become more prevalent within the vendor space, which is a good thing.
Certainly, some vendors are rising to the top in terms of understanding how to deliver that experience at an affordable and competitive rate, while still putting the patient experience at the center. I think it’s going to be interesting to see how the landscape changes in the near future, as the vendors start to fill that void, especially with robotic process automation and to see who is leading the industry in delivering solutions in a more affordable and superior way.
Stack: Amy, do you find that some of those vendors plug and play better with your electronic health record (EHR)?
Assenmacher: Yes, that’s important. We put our electronic health record as the first option when developing a solution, and if we can’t do that, we look outside and figure out who can best integrate or interface with our EHR, because that’s our long-term platform.
Martin: What does the governance process look like for your organization as it relates to choosing and coordinating payer-provider data-sharing efforts with third parties? How will the newest HIPAA regulations regarding limitations on third-party access to electronic protected public health information (ePHI) impact these efforts?
Hoffman: Organizations need a highly developed governance structure that encompasses IT, the revenue cycle and clinical support operations. Having worked with several large systems, I’ve seen a lot of variability. I have not seen in any organization (not to say that they don’t exist) a really cohesive, well-
integrated process. In more mature organizations, one component might be very well fine-tuned, but other pieces that should be integrated are not.
Blair: At CentraCare, the data governance model is still evolving. Before I came to CentraCare, I worked at the health system of the University of
Missouri and they had a well-built model. We had monthly governance committee meetings, including physician leaders, operations, administration, academic leaders and IT. A cross-organizational group would make decisions about which software we were going to use and our informatics priorities. I’d like to replicate that model here at CentraCare because it had all the key players at the table and discussions were really robust.
Alice Heinrichs: We have somewhat of a similar type of model in our organization. It’s been derailed a bit by the pandemic, but we certainly have a steering
committee that meets regularly. We also have a sub-committee that reviews and makes decisions about the modules of the EHR and reports up to the overarching steering committee. Additionally, we have a separate group looking at reporting needs within our EHR.
Allers: We have developed a governance structure monitoring and reporting where all of our data is going: What goes to the state registry, what goes to our EHR vendor and to other places. We know where we’re sending our data and use that information internally as we make decisions.
Heinrichs: Data is an asset, and we should be managing that really well. But it’s very challenging, with data going out to many different places, including the Iowa Hospital Association, the state and the CDC (Centers for Disease Control and Prevention). All of these different organizations are requesting data. How do you safeguard it? How do you make sure that you are sending out clean and good data to begin with? Remember, the data is being used to make decisions that will impact your organization down the road.
HFMA Roundtable Panelists
Revenue cycle director, Van Diest Medical Center (MercyOne affiliate), Webster City, Iowa
CFO at Mid-Columbia Medical Center, The Dalles, Oregon
Senior vice president, revenue cycle at Spectrum Health, Grand Rapids, Michigan
CFO at CentraCare Health, St. Cloud, Minnesota
Vice president, revenue cycle, Nebraska Medical Center (Nebraska Medicine network), Omaha, Nebraska
Consultant, Warbird Consulting Partners, Atlanta, Georgia
CFO at Van Diest Medical Center (MercyOne) in Webster City, Iowa
Vice president, financial alignment, Cerner, Kansas City, Missouri
Director, perspectives and analysis, HFMA, Washington, D.C.
Cerner health technologies connect people and information systems at thousands of contracted provider facilities worldwide dedicated to creating smarter and better care for individuals and communities. Recognized globally for innovation, Cerner assists clinicians in making care decisions and assists organizations in managing the health of their populations. The company also offers an integrated clinical and financial system to help manage day-to-day revenue functions, as well as a wide range of services to support clinical, financial and operational needs, focused on people.
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