Putting the “P’ in Interoperability: Payer Problems

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Wednesday, 28 January 2015 16:20

In previous articles, we have argued that disorganized systems within the hospital networks have kept caregivers from accessing and using critical patient data effectively. In this final installment of our three-part series on interoperability, we’re addressing current challenges from the perspective of the healthcare payer (i.e. Insurers, including Centers for Medicare and Medicaid Services (CMS), commercial insurance, employer plans, and third party administrators). We’ll take a closer look at how this current lack of interoperability impacts payers, and then we’ll discuss how connected and integrated medical data can provide better coverage for patients while helping to lower the overall cost of care for all involved.

How interoperability currently impacts the payer environment:
Rising cost of chronic disease management has led to increased costs for insurance companies and other payers. In addition, healthcare reform and the Affordable Healthcare Act have forced payers to take on an increased patient population which was not previously insured, with little to no documented historical data. Payers are struggling to set premiums based on unknown parameters, and have consequently increased premiums over the years, to the dismay of both providers and patients.

As records from physicians and patients don’t always sync, one major consequence of the current lack of interoperability comes from errors in patient records that lead to incorrect billing and reimbursements. If insurance companies do not receive accurate admission, discharge and transfer messaging from providers who are managing a patient’s chronic condition, they’ll be faced with readmission, claim denials or back-office rework. In addition, improper documentation of patient testing records can lead to duplicate claims, which have become a common problem in the payer setting.

Current health plans tend to focus more on the cost to treat patients rather than patient outcomes, but this is changing, and payers, along with the CMS, are looking for ways to make providers more accountable for performance and patient care. Many private payers currently follow CMS guidelines for issues of penalties and reimbursement, but would benefit from having their own set of data to make accurate claim decisions. Interoperability may offer one path to achieving these goals.

Benefits of Interoperability to Payers:
By developing standards of interoperability with providers via a health care data exchange, providers and payers can maximize efficiencies, cut costs, and also learn from patient data to improve coverage offerings.

Current efforts to achieve interoperability through investing in health information exchanges appears to primarily benefit providers, as it facilitates the sharing of patient data with other providers. However, the collaboration and improved data movement can also benefit payers in many ways. Some of these benefits include:

Payers Need to Play their Part
The current lack of interoperability within the healthcare system affects everyone involved. While providers have stepped forward, with the help of vendors and the government, to work toward a system of interoperability, payers must be open to collaboration to make this a success, and thus play an essential role in this process. When all three groups — patients, providers and payers — start to share more information electronically, they will allow for a continuum of care for patients who deserve the best coverage and care available. Despite the initial lack of financial incentives for payers, interoperability can save them time, money and resources. While the primary benefit of interoperability for payers involves more efficient, cost-effective and accurate claims processing, as health care interoperability evolves, additional benefits will continue to emerge for all parties.