My 5 Answers to 5 JASON Report Questions: Sept. 26 #HITsm Tweetchat

Many thanks to Greg Meyer, distinguished engineer at Cerner (and @Greg_Meyer93 on Twitter), for moderating this week’s #HITsm tweetchat about the JASON Report.

Every Friday, from Noon to 1:00 EST as many as a hundred or so #HITsm (Health Information Technology Social Media) pundits, plus possibly thousands of lurkers, and tens of thousands of innocent bystanders experience #HITsm tweetchat. Sometimes I even write a #HITsm themed blog post (such as this one) and tweet links to specific paragraphs. Such is the case today for discussion of the JASON Report.

The first half of this blog post is background, which I encourage you to read. But you can also jump directly to the #HITsm topics and my answers:

I’ve already written about what I think of the JASON Report in a blog post titled Out Of The Health IT Tar Pit: My Comments on A Robust Health Data Infrastructure. I’ve tweeted about the JASON Report too. Of course, I tweet a lot about a lot period. Anyway, I’ve embedded some of those tweets below, thematically connected to one or more of each of the five #HITsm questions.

Here’s my initial reaction (before I wrote my incisive commentary).

Reactions to the JASON Report have been varied. From, “See, I told you so!” to muted defensiveness. My reaction was mixed too. On one hand I agree that Meaningful Use has not be particularly effective regarding to the goal of ubiquitous and seamless patient data interoperability. On the other hand, I’m not particularly impressed or a fan of more top-down mandated health IT architectures or initiatives. By the way, my reference to OSI, Open Systems Interconnection, in the following tweet? TCP/IP won that battle. (OSI: The Internet That Wasn’t: How TCP/IP eclipsed the Open Systems Interconnection standards to become the global protocol for computer networking and The “good guys,” led by Cerf, Kahn, Walden, and others defeated the governments, PTTs, and giant corporations by using well-engineered, open protocols — stuff that worked and was robust.)

Then there’s my actual blog post about the JASON Report.

From my post:

Out Of The Tar Pit is about why software is so difficult. Software is difficult because it is complex, by which the authors mean it is difficult to understand (not the more formal concept of computational complexity). They list reasons — state, control, and code volume — to which I will return.

Why did I think of Out Of The Tar Pit when I read the JASON report? Because software architectures are about managing, attempting to reduce by design, complexity, to get to more understandable and reliable software systems. Divide and conquer: if we can reduce a software system into understandable components, and understand their interactions, we can hope to understand the whole, and make it do what we wish more reliably.

So far, so good. The JASON-suggested software architecture for healthcare information exchange is a valiant effort. It’s only missing one key ingredient: process-aware information systems. Now, the architecture is, indeed, intended to be agnostic about what specific software platforms should be used to implement it. I, however, am not agnostic. I believe, without a doubt, that many of health IT’s problems regarding usability, interoperability, and cost, are due to not using technologies that have been prevalent in other industries for years, in some cases, even decades. These are the workflow technologies, including workflow management systems, business process management, and dynamic and case management systems.

Workflow tech is used by, embedded in, a wide variety of social, mobile, analytics and cloud platforms. From speech recognition and natural language processing systems to “big data” and machine learning workflows, executable process models are helping to manage software complexity, increase understandability and reliability. I will visit some of the boxes of this architecture in a later post: stovepipe legacy systems, UI apps, middleware apps, semantics and language translation, as well as privacy services. However, before I do so we need to review the major sources of software complexity the JASON architecture seeks to tame.

Out Of The Tar Pit blames software complexity on

  • state (data values)
  • control (order of execution) and
  • code volume (lines of text).

Out Of The Tar Pit suggests programmers think more declaratively about what the software does, not how it is accomplished. This would go a long way to reduce software complexity. In other words, if health IT could better manage software state, control, and code volume, this would go a long way toward accomplishing the same higher-level goal that motivates the JASON architecture.

The better health IT manages state, control, and code volume, the more it will reduce complexity and achieve goals motivating the JASON architecture. On all three points, workflow technology contributes.”

At this point I’ll relegate the rest of my tweets to the end of this post, except the following:

The JASON Report is not a solution. It is a symptom of health IT’s workflow-oblivious infrastructure, tools, and mindset. The solution is to attack workflow oblivity itself. In this regard, I hold this weekly #HITsm tweetchat in high regard! It’s half technical and half social. As long as I show up and respect shared conventions and etiquette (more-or-less) I get to blather on about workflow and workflow tech, and the very nice #HITsm folks let me. Sometimes they intentionally push my buttons, so to speak, since I’m predictably consistent when it comes to jumping on every possible workflow-related tweet or angle.

So, finally, this week’s #HITsm questions (and my answers):

Topic 1: Has MU “achieved meaning interoperability ‘in any practical sense’”? Does the report downplay progress since its research period? #HITsm

I’d like to reword this question: Has MU “achieved meaning interoperability ‘in any pragmatic sense’”? I’d argue that what has been missing from health IT interoperability initiatives, focusing on syntactic and semantic interoperability, is Pragmatic Interoperability. Even when syntactic and semantic interoperability are achieved, it’s not flexible or scalable. That requires the next level up, of pragmatic interoperability. And the best infrastructure and tools to achieve pragmatic interoperability is workflow technology, particularly BPM (Business Process Management) and related technologies. Check out my longer post on this: From Syntactic & Semantic To Pragmatic Interoperability In Healthcare.

Topic 2: Should public APIs become a requirement in MU3, & is MU an effective method to accelerate change? Is the approach too aggressive? #HITsm

I’ve already answered this question, during a previous #HITsm chat.

Design of great interfaces, computer-to-computer (APIs) or human-to-computer (usability) cannot be mandated. Rush them. Try to do too much. You’ll get crappy interfaces. Instead, encourage, raise consciousness, fund research, create and share reference implementations, hold contests, anything! Just. Don’t. Mandate. The combination of a long list of features and a hard deadline just causes misery, for programmers, for users, and, ultimately, for patients.

Topic 3: Should ONC mandate a detailed #HealthIt architecture or should they simply recommend “patterns” and leave impl details to vendors? #HITsm

See my previous answer to Topic 2.

Topic 4: What impact do factors (barriers?) such as legal/policy, jurisdiction, & biz models play on interop and how do we mitigate them? #HITsm

First, just as the US funded the creation of the Federal interstate highway system, we should have funded a means to securely transmit healthcare data, with a focus on both security AND cost. By keeping the cost low, new transportation companies came into existence. New health IT companies would have, and will, if we still proceed in this direction. However mandating the structure (syntax) and content (semantics) has the opposite effect. By analogy, it’d be like mandating what and who trucks and cars carry. In spite of belief these efforts reduce cost, it’s has had the effect of preventing entry of new and innovative companies into the health IT space.

Second: An emerging, model for government policy and support for technological innovation is how the Maker Movement is beginning to be recognized as a force for “re-industrialization” of America. From White House Maker Faires to seeding technology to schools to convening and facilitating routes and means for turning prototypes into products, the urge to create solutions to problems is universal human urge. Frankly, I’m not sure exactly how to operationalize this relative to interoperability, but we need to support TCP/IP approaches to health IT interoperability, not OSI approaches (see above). For more on this topic, see my National Health IT Week Thoughts: Let’s Replace “Meaningful Use” With “Meaningful Creation” or, Health IT, Join The Maker Movement!.

Topic 5: Is a new “common data-level API” needed for clinical research, or are current models sufficient? What’s the patient’s role? #HITsm

By all means! Just. Don’t. Mandate. It. If it’s any good, folks will use it. If not, it will deserve to fail in the market place of both ideas and products and services. The patient’s role? Well, if they’re really good at designing APIs (such an intersection is surely not null) encourage them to do so.

Again, many thanks to Greg Meyer, distinguished engineer at Cerner (and @Greg_Meyer93 on Twitter), for moderating this week’s #HITsm tweetchat about the JASON Report.

P.S. Here are the rest of those tweets I mentioned. Feel free to RT!

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National Health IT Week Thoughts: Let’s Replace “Meaningful Use” With “Meaningful Creation” or, Health IT, Join The Maker Movement!

After a lengthy preamble (I like lengthy preambles, to write them, that is!) I’ll answer each to this week’s (Friday, Noon, EST) #HITsm tweetchat questions.

  1. Topic 1: What #healthIT value proposition would you prioritize for Congress? How will their buy-in/participation drive long-term change? #HITsm
  2. Topic 2: How can federal agencies more significantly impact progressive #healthIT implementation and use for their stakeholders? #HITsm
  3. Topic 3: How can #healthcare balance clinical needs for evidence-based mobile medicine & consumer demand for behavior change tech? #HITsm
  4. Topic 4: Reflecting on another great #NHITweek, what have you observed as missing from the collective #healthIT conversation? #HITsm

I’d like to make an immodest proposal. Instead of debating whether to call healthcare users patients or consumers, let’s replace that whole consumers-who-use-healthcare paradigm with producers-who-create-health.

Huh? OK, that “sounds” great, but what do you (I) really mean? I mean health IT should become more like the Maker Movement. Here’s how Wikipedia describes Maker Culture:

“‘Maker culture’ emphasizes learning-through-doing (constructivism) in a social environment. Maker culture emphasizes informal, networked, peer-led, and shared learning motivated by fun and self-fulfillment.[2] Maker culture encourages novel applications of technologies, and the exploration of intersections between traditionally separate domains and ways of working including metal-working, calligraphy, film making, and computer programming. Community interaction and knowledge sharing are often mediated through networked technologies, with websites and social media tools forming the basis of knowledge repositories and a central channel for information sharing and exchange of ideas, and focused through social meetings in shared spaces such as hackspaces. Maker culture has attracted the interest of educators concerned about students’ disengagement from STEM subjects (science, technology, engineering and mathematics) in formal educational settings. Maker culture is seen as having the potential to contribute to a more participatory approach and create new pathways into topics that will make them more alive and relevant to learners.” (my emphasis)

What would a Health IT Maker Movement look like?

First of all we should examine what might seem like obvious differences between what Makers do and what Health IT people do. (I’ll use some simplistic stereotypes here…) Health IT people write (test, install, train, maintain…) software. Makers make physical things. Health IT saves lives. Makers make gadgets, interactive toys, performance art, that entertain, well, mostly other Makers. Health IT people mostly do what bureaucrats tell them. Makers mostly don’t.

Now let me be clear. When I’m sick, I don’t want to be dependent on some hobbyist’s personally soldered heart monitor. However, Health IT could surely use a good dose of whatever it is those Maker’s are… well never mind that. What I am talking about here is thinking different, figuring out how to do it cheap, and, most important, the energizing feeling of empowerment that comes from taking control of the means of production. That last phrase? No, I’m not a socialist. I’m a good-ol-fashioned American small business capitalist. I’d like to see us return to our roots, our invented-in-a-garage-roots, as in can you say Apple Computer?

One more thing! (Before I get to this week’s four #HITsm questions.) Think about this. If we can put tools in the hands of physicians to create their own workflows… If we can put fashionable wearables on the wrists and other body parts of… of … I think I’ll call them “im-patients”, maybe we can finally begin to create the out-of-office physician/patient workflows we need.

Topic 1: What #healthIT value proposition would you prioritize for Congress? How will their buy-in/participation drive long-term change? #HITsm

Turn patients and providers into inventors and producers of healthcare and health, instead of consumers and users.

Topic 2: How can federal agencies more significantly impact progressive #healthIT implementation and use for their stakeholders? #HITsm

Playing a supportive, not directive, role, much as the some federal agencies are beginning to support makers and factories re-kickstart American manufacturing.

Topic 3: How can #healthcare balance clinical needs for evidence-based mobile medicine & consumer demand for behavior change tech? #HITsm

Instead of focusing on getting patient-generated data into the EHR, focus on getting EHR data into the wearable (and associated apps). By the way, consumers aren’t demanding behavior change tech. No one likes change. Seed and fund STEM (and SHTEAM) Maker-style facilities, resources, gatherings and initiatives. Convert consumers from users to im-patient health producers. Harness their insight and lived experience to create “behavior change tech” that doesn’t look or sound like “behavior change tech.”

Topic 4: Reflecting on another great #NHITweek, what have you observed as missing from the collective #healthIT conversation? #HITsm

Workflow.

Workflow “is” the interface between people and technology. Most problems with usability, blamed for lack of EHR and HIT adoption, boils down to problems with workflow. Just as the Maker Movement emphasizes putting physical tools in the hands of the people, let’s put IT tools in the hands of the people. Just as it would be inappropriate to put million dollar factory machinery in the hands of the people, so we put 3D printers and easy-to-use microelectronics there, lets put easy-to-use workflow tech into the hands of clinicians, so the folks who know their workflows best can design the workflows of the systems they use to do their work.

I’ll wind up with a quote from the Maker Movement Manifesto:

“Making is fundamental to what it means to be human. We must make, create, and express ourselves to feel whole. There is something unique about making physical things. These things are like little pieces of us and seem to embody portions of our souls.”

P.S. While making physical objects can be empowering, programming is empowering too. So when I speak of a Health IT Maker Movement I include both fabrication and programming in its empowering machinery. Many of the “physical things” Makers make are interactive, intelligent, talking to the cloud, communicate with other physical things. And the medium that makes this possible is software. But I don’t want physicians programming in Java and C#! (unless they want to) I want physicians to take back control of their workflows by programming their workflows. This kind of programming, relying on graphical editors and editable workflow checklists, does *not* require a degree in computer science.

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Patient Engagement and Wearable Technology: From Around The Web

Today I’m attending the Consumer Health IT Summit AND working on my slides for a webinar tomorrow,Wearable Workflow Needs Health Systems Engineering (register here). (And following tweets from the HBMA conference and writing this blog post!) Tomorrow’s webinar is about wearables and classic concerns of industrial engineering in healthcare, namely work (and workflow) improvement. But patients, patient experience, and patient engagement are becoming so important to improving healthcare workflow. And wearables are becoming a key component of patient experience and engagement. So, I cross-indexed “wearables” and “patient engagement” and found the following articles and quotes. I’d be interested your take on them.

Blog: Healthcare Apps and Wearables – A Gateway to Patient Engagement?

“The information must flow without the patient having to facilitate it. Physicians must be part of the process of evaluating the engagement. With the world of wearables only in its infancy, interoperability of the network needs to define and drive how these independent silos will interact. When this networked transformation happens, the power of the system will far exceed that of the isolated patient or physician operating independently. Over time, this data will be combined with a complete health record to provide truly personalized medical updates and a comprehensive view of your health and habits, thus filling in all the gaps between medical checkups and doctor visits.”

…presenters and vendors to stress patient engagement through mobile health technology and workflow

“Wearable technologies … are taking connected health to the next level since some patients leave their mobile device at home or in the car. By having a device that is constantly worn on the body, patients can be empowered in a way that was not possible before. Some of these connected “wearables” are monitoring biometrics like heart rate and respiration. Others are simply detecting patient movement and sending reminders and alerts. We are seeing an evolution of wearables interacting with mobile devices and other ecosystems of connected health that already exist within the home. Bluetooth, Wi-Fi, 3G/4G and near field communication radios and sensors are all working together to keep patients connected like never before.”

The Future Of Healthcare And Wearables

“Healthcare in general is being impacted by an aging population, which means we need to devise new strategies and technology to help individuals better manage their own health (e.g. obesity), which will improve outcomes, increase longevity, and also help manage costs,” he said. “Behavior change is integral to achieving this goal; as Lord Kelvin stated: ‘To measure is to know. If you can not measure it, you can not improve it.’ Wearables are key to patient engagement….

the biggest challenge is integrating this data into the existing workflow and health IT systems. As a patient, Dr. Nick says that “there is no pathway for me to record, report, and include my data. Take a simple example of my blood pressure. My doctor has no way of including this in my electronic medical record (EMR) and is not included in his workflow. There are some exceptions, but this information needs to be captured consistently, flow to the doctor, and then the EMR for it to be part of the standard practice and care.”

Wearable Technology: The Coming Revolution in Healthcare

“the adoption of wearable healthcare-related devices could indeed be a significant step in patient engagement and improving population health — two critical success factors driving today’s increasingly complex healthcare environment. Specifically, wearable health technology brings three distinctly beneficial trends to the table — connected information, community, and gamification. By harnessing this trifecta, healthcare leaders have new ways to build engagement and create accurate, far-reaching views of both personal and population health….By bringing together people with a common interest such as weight loss, wearables serve as a mechanism to build engagement and at the same time compile information….Healthcare organizations can tap the power of that data to engage patients and develop more effective and more personalized approaches to care, thereby lowering the overall cost of care.”

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Happy National HIT Week From Mr RIMP! (Robot-In-My-Pocket/Patient Engagement Badge)

Mr. RIMP is an interactive “wearable robot” who (not “that”!) lives in physicians’ and child life specialists’ pockets. He’s designed to “engage” and thereby entertain and distract children from perhaps arduous circumstances. In fact, Mr. RIMP used to have a different name! Based on “Interactive Graphical Engagement Badge”, it was “Iggy, B”. This was based on a failed attempt to create an acronym based on the phrase “Patient Engagement Badge.” Mr. RIMP is so much happier now being called “Mr. RIMP”! :)

From YouTube description:

Mr RIMP (@MrRIMP) is a Bluetooth-controlled, 3D-printed wearable robot who lives in Dr. Chuck Webster’s pocket (@wareFLO). Kids, pediatricians and child life specialists love him. And HE loves Health Information Technology! He learned to say it as part of John Lynn’s social media project to celebrate National Health IT Week. Happy #NHITweek!

Many thanks to @HIMSS for tweeting MR. RIMP’s video (saying “I love Health Information Technology!”) out to over 50,000 Twitter followers!

P.S. Mr. RIMP is made of 3D printing, Arduino, and Bluetooth, and can talk to other Bluetooth-enabled devices. He’s a fun platform to explore what Dr. Webster calls “wearable workflow”. If you’d like to learn more about healthcare wearable workflow, checkout the webinar Wearable Workflow Requires Health Systems Engineering, or, better yet, attend the Healthcare Systems Process Improvement Conference in February, Orlando. Dr. Webster will give a keynote on the subject. And Mr. RIMP might make a guest appearance!

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Patient Eligibility Verification 10-Part Interview: Vishal Gandhi of ClinicSpectrum, Booth #301 at HBMA

After the resounding success of our recent 10-Part medical practice workflow Interview with Vishal Gandhi of ClinicSpectrum, well, why not do it again?!

However, even I, a glutton for workflow punishment, couldn’t do *another* 10-part interview about workflow with the same, undeniably smart and multi-faceted person, such as Vishal! So I let V. pick the topic: Patient Insurance Eligibility Verification. Back when I was CMIO for an ambulatory EHR vendor for over a decade, we dealt with eligibility verification, but boy has it gotten complicated since then! So I learned so much during this, intentionally in-the-weeds, interview with Mr. Gandhi.

I’m sure Vishal would appreciate me adding, he and his company, ClinicSpectrum, is located in booth #301 at the Healthcare Billing Management Association Conference in September 14-16 in Las Vegas. :)

By the way, I’ve left the words and phrases IN ALL CAPS exactly I as got them from Vishal. :)

  1. The 2014 Consumer Health IT Summit is happening September 14 (same day as the HBMA Conference) in Washington DC. It’s about empowering patients with their digital data and technology. So my first question is: From a patient engagement perspective and the patient’s point-of-view what are benefits of a well-run medical office patient insurance workflow?
  2. What are typical limitations of EHR/Practice Management systems? And how does ClinicSpectrum eliminate them?
  3. What kinds of information about a patient’s eligibility verification are NOT available through software technology interfaces?
  4. What are some Do’s and Don’ts when calling to inquire about covered vs. un-covered procedures?
  5. Once you know a patient’s eligible benefits (high deductible, non-covered, max caps, etc.) what are appropriate action plans?
  6. What are typical percentages of denials due to eligibility issues? How much can these percentages be reduced through a more proactive approach?
  7. Tell me about your medical office Micro Finance Company analogy. What are some workflow management implications?
  8. As deductibles go up, how can medical practice begin to manage their patients’ “viability” of paying their portions of the bill?
  9. What’s is best and most cost effective manner to follow up on balances through a “soft” collection method?
  10. Where do you see Eligibility/Benefit Verification going years from now? How will it fit into larger population health and care coordination landscape?

Into the weeds!

The 2014 Consumer Health IT Summit is happening September 14 (same day as the HBMA Conference) in Washington DC. It’s about empowering patients with their digital data and technology. So my first question is: From a patient engagement perspective and the patient’s point-of-view what are benefits of a well-run medical office patient insurance workflow?

A well-run medical office patient insurance workflow results in a lower cost of care by health plan and a lower cost for patient. Plus, patients don’t like to be surprised with lot of medical bills unpaid by their health plans! So, a clear idea of health plan benefits, covered and uncovered tests/procedures in outpatient and inpatient set up is of utmost necessity. Excellent patient insurance workflow contributes to a healthy relationship among the patient, their clinical needs and heath insurance coverage in today’s changing healthcare space due to ACA and ACO.

What are typical limitations of EHR/Practice Management systems? And how does ClinicSpectrum eliminate them?

Any efficient workflow engine has balanced combination of automation and human element which follows certain protocols and processes. EHR/PM is definitely an essential element of workflow in a medical practice; however it does not substitute the requirement of human element or man power in effective practice management.

First and foremost common limitation of EHR/PM systems is eligibility verification. While some software offers online Verification of Benefits, more often than not the information does not have enough detail about various procedure codes covered, amount met-to date, coinsurance, and specific benefit information, leading to higher chance of denials after services have been rendered.

ClinicSpectrum’s eligibility verification team overcomes limitations of EHR/PM by making calls to Insurance Representatives for detailed Verification of Benefits. Each call lasts over 30 mins and results into answers to several questions related to patient’s health plan as per customized templates provided by the medical group.

The second human element comprises of filing scanned/faxed documents into EHR system. It is essential for provider to have necessary clinical information at the time of service including all tests and procedures done within office and outside. ClinicSpectrum’s indexing team focuses on filing these documents into patients’ chart with proper identification, date and description. All documents scanned/faxed are indexed in a timely and cost effective manner. Total cost savings in indexing documents with ClinicSpectrum’s team is up to 40% compared to practice’s own staff.

The third human element is requirement of preparing or studying gap in patient’s care plan or risk management. This requires clinician or medical assistants to review active problems, allergies, treatments and procedures and preparing personalized prevention plan. It is difficult for physicians to review all this information even though most EHR’s have some sort of decision support. ClinicSpectrum’s clinical team helps providers in Population Management, Care Plan oversight and Recalls for required Preventive Tests/Procedures.

Last and most crucial human element is tracking/follow up of claims submitted to insurance companies. Even though most EHR/PM systems submit claims to Insurance companies’ electronically, it is a known fact that 18 to 24% of claims are unpaid or require some sort of tracking and follow up. Claim Tracking through EHR/PM system is limited in its capabilities and same is the case with ONLINE or INSURANCE companies’ website. It is essential to make a phone call to the insurance company and question their reason for denial or non-payment of a claim beyond 30 days. ClinicSpectrum’s Accounts Receivable Follow up team specializes in chasing insurance companies’ for outstanding claims until they are paid.

What kinds of information about a patient’s eligibility verification are NOT available through software technology interfaces?

Eligibility verification is a crucial aspect of running a business whether you work for a billing company or physician’s practice. With an additional 30 million uninsured Americans now receiving healthcare coverage under the Affordable Care Act, verifying procedure benefits, prior authorizations, referral requirements if applicable, and covered and non-covered conditions for certain procedures is imperative. Without such verification, you will likely experience high levels of insurance denials and lost revenue. ClinicSpectrum has been around the block and has helped numerous practices and companies get on the right track with eligibility which are not available through software technology interfaces. In fact, we frequently hear of many misconceptions when it comes to eligibility checking. While these may seem harmless, or “no-brainers,” these misconceptions can actually hurt your workflow and revenue. For example:

Misconception #1: Clearinghouses have all the answers.

Unfortunately, this just isn’t true. Clearinghouses certainly have an enormous amount of information and technical capabilities to gather some eligibility information, but it isn’t guaranteed to be accurate or thorough enough. To get speedy and accurate verification, you need live representation and phone calls from knowledgeable professionals.

Misconception #2: The EHR verification has all the information I need.

Anytime an EHR allows you to have Level 1 verification, it’s very basic. Too basic, in fact. You will likely not have access to specific diagnostic codes and procedures, precert authorizations, detailed answers to questions specific to each speciality. In fact, ClinicSpectrum can work off of the practice’s Verification of Benefits template to ask for specific details relevant to that procedure.

What are some Do’s and Don’ts when calling to inquire about covered vs. un-covered procedures?

It is essential to define covered vs. un-covered procedures. Almost all health plans have certain policy guidelines under which they would pay for claims from providers.

Health Insurance companies’ come out with variety of plans ranging from lower premiums to higher premiums. It is obvious that plans with lower premiums would have less coverage than those with higher premiums.
With Obamacare and Health Insurance Exchange, there is a minimum threshold of coverage, this enforces health plan to put lot of conditions for various treatments, procedures and hospitalizations.
It is essential for provider’s office to know covered and un-covered procedures in outpatient/inpatient and office setting. For example, several plans have office visits non-covered whereas well visit or physicals are covered benefits. This simply means that provider’s office would not get paid for office visit related to some sort of clinical conditions.

It is a common practice for health plans to provide coverage for hospitals owned diagnostic centers and no-coverage for free standing independent diagnostic/radiology centers. Insurance companies’ manage their coverage network or participation network as well. It may happen that provider’s office may have to locate IN NETWORK physicians/facilities for their patients in order for certain procedures.
Let’s take a look at some examples of questions required to be asked.

We need to define specific questions for coverage pertaining to your specialty of practice.

  • Asking for place of service for coverage
  • Asking for in network facilities for coverage of procedures
  • Medical Necessity / Clinical Requirements for coverage for procedures
  • Frequency limitations if any
  • Maximum allowed amount for particular procedure
  • Requirement of Authorization for Procedures
  • Deductible applicable for the procedure

Once you know a patient’s eligible benefits (high deductible, non-covered, max caps, etc.) what are appropriate action plans?

The first step to improving patient collections is to really understand the details of your patient’s insurance plan. This starts with doing an insurance eligibility check and verifying your patient’s plan details. We wrote about ways to streamline your insurance eligibility checks previously. Doing it right takes time, but with the right workflow automation solutions you can make sure that those working in your practice have the right insurance information. Once they have the right payment information, you’re much more likely to collect the payment from the patient while they’re standing in front of you at the office.

While collecting the patient payment from the patient while they’re in your office is ideal, there are dozens of reasons why this won’t happen. Some don’t have the money at the time. Some walk out before you can collect. Etc etc etc. How then do you engage the patient in the payment process once they’ve left your office? In the past, the best solution was to send out bill after bill through the US postal service or possibly call the patient directly. This is an extremely time consuming and costly process that can take 60 to 90 days to obtain results. Plus, it costs several hours of man power and postage.

In the electronic world we live in, the first thing you can do to improve your patient collection process is to implement an online patient payment portal. This online payment process increases patient collections dramatically. The next generation patient is so unfamiliar with writing checks and sending snail mail, that those payments often get delayed. However, by offering the online patient payment option, you remove this barrier to payment.

The other way to improve patient collections is to use an automated messaging and collection process. This approach uses a collection of text, secure text, email, secure email and even smart phone notifications and automated calls in order to ensure the patient knows about their bill and has the opportunity to pay the bill. Plus, these customized decision rules provide a much more seamless and consistent approach to collections.

What are typical percentages of denials due to eligibility issues? How much can these percentages be reduced through a more proactive approach?

Research reveals that 75 percent of all healthcare claim denials are due to the patient being ineligible for services billed to the insurer by the provider. Primary reasons why claims get denied are:

  • Patient’s demographic info doesn’t match health plan database
  • Patient has COB and health plan thinks they are secondary
  • Treatment/Procedure require prior authorization
  • Calendar year max reached for the benefits
  • Patient is not eligible at the time of service
  • Visits require referral from primary care provider
  • Visit applied to patient’s calendar year deductible
  • Provider is not member’s PCP
  • Services provided are not deemed medically necessary as per plan policy

Most of the above denials are due to in appropriate eligibility verification. It would be beneficial for practice to invest time in verification of benefit through a Live Insurance Representative. This would result into reduction of above denials. At least 50% of the amount noted can be reduces if a more proactive approach is taken by the staff.

Tell me about your medical office Micro Finance Company analogy. What are some workflow management implications?

Patient Responsibility for an office visit has increased from $10-15/visit to $30-$40/visit. Most of the employers are promoting “HRA/HSA” Plans. Health Insurance Plans marketed in healthcare market place has minimum deductible starting from $750.00 onwards.

Patient would have 3-4 visits/year to their primary care and/or specialist office. It is obvious that all of these visits would be applied to deductibles. Health Plan would reimburse money to providers’ offices only if the calendar year deductible is met. In a nutshell, the patient has to spend money for health insurance every month + out of pocket expenses per visit and medications.

It would be extremely difficult for several patients to spend this kind of money towards the cost of their care. It is even more difficult for providers to demand (or) force patients to pay such high costs up front.

Payment Plan/Micro Financing would be an essential element in the practice, just like Dentists or any other out of network surgeons or plastic surgeons. When your required money to take care of expenses is higher than your liquidity, people turn to financing.

Micro Finance is a field evolved out of financing smaller balances or loans. CareCredit is a perfect example of such a concept. Lots of patients may not qualify for THIRD PARTY finance companies. In this case, a practice may have to trust patients and hedge risk to finance their balances by making an appropriate payment plan.

It would be practically impossible for a practice to make payment plans without proper automation, tracking and reminder software such as AutoCollectSpectrum.

As deductibles go up, how can medical practice begin to manage their patients’ “viability” of paying their portions of the bill?

A practice needs to commit to certain workflow and policies in order to deal with patients’ portion of the bill. Let’s analyze the necessary steps below:

1) Practice needs to check detailed verification of benefit through a representative call and find out applicable deductible/copay/coinsurance and non-covered services for all tests/procedures applicable to the practice.

2) Practice should have a defined financial counselor who calls patients in advance and explains his/her benefits and his possible cost of first visit/second visit or tests/procedures beforehand. A trained financial counselor will not scare patienst but would collaborate with the patient and convey a strong message that “we will work with you”.

3) At the time of check-in, practice can collect CREDIT CARD or POST DATED CHECK on file towards an estimated patient responsibility portion. If patient is unable to pay this up front, he/she may be offered a payment plan.

4) Practice should have some kind of automation tool for engaging patients for their financial responsibility.

5) Practice may need some sort of automation tool to send invoice for the payment plan and auto processing of credit card towards payment plan or patient responsibility portion if authorized in advance by the patient.

6) Practice may need automation to reach out patients with high balances or unpaid balances through automated call, text, secure text and secure email.

With the above defined process, protocol and automation, practice can deal with patient portion of the bill much more effectively.

What’s is best and most cost effective manner to follow up on balances through a “soft” collection method.

As the name implies, a soft collection is a less severe form of collection. Practice will directly engage their staff to invoke urgency of outstanding balance through nicely drafted communications or letters. The practice will send increasingly urgent letters and make increasingly urgent phone calls to patients for balance collection.

In healthcare practice, secretarial hours required to do same job has increased by 30% over last 3 years due to increased audits, authorizations and medical necessity. It is increasingly difficult for practice to devote time towards soft collection utilizing its own team.

It is an industry trend to outsource collections to a THIRD PARTY COLLECTIONS agency, however most of these agencies use hard collection methods resulting in loss of active patients at times.

AUTOCOLLECTSPECTRUM automates the traditional collection methods of standard mail delivery and costly representative phone calls, to a more elaborate, seamless, cost eff­ective auto collection process. The automated collection methods with use of Technology Platform, Decisions Rules and Messaging such as Text, Secure Text, Email, Secure Email, Push notifications on Smart Phones and automated calls, allow seamless, consistent, proven results for balance collection.

Our proprietary collection method, delivers traditional communication means of letters and calls via an automated messaging channel. The debtor is relentlessly followed up for balance collection through decision rules customizable by the user. The date, time, hour and frequency of calls is auto set-up and notifications are delivered to the debtor simultaneously via our messaging methods.

BENEFITS OF AUTOCOLLECTSPECTRUM

By eliminating representative involvement and automating the process, the collector reduces his/her cost and increases the chances of outstanding collections. Following extensive auto collection efforts of balance recovery, if the debtor is non-responsive, he/she can be reported to Credit Bureaus automatically and/or sent to Legal Department for further legal proceedings.

Where do you see Eligibility/Benefit Verification going years from now? How will it fit into larger population health and care coordination landscape?

I strongly believe that Medical Policies for each plan will be programmed, and very soon front end adjudication engines will take over this function determining Procedure Level requirements and Medical Necessity (beforehand). This will lead into major efficiency in overall workflow management however this will also increase DEALING WITH HIGHER AND HIGHER patient responsibility. So practically speaking, medical offices would turn into Micro Finance Companies’ as the patients’ would never have the proper financing for care and Practices would end up making payment plans or find some outside Micro Finance Companies’ to fund the Patient Responsibilities’ portion.

That’s a wrap! I’d like to thank Vishal for sharing his passion for eligibility verification. Anyone who SPRINKLES EXPLANATIONS WITH ALL CAPS really cares. :)

Until next time… Vishal & Chuck!

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