While the word "healthcare" can be heard everywhere these days, how exactly do healthcare organizations achieve their goals of improving patient care and ensuring profitability? One of the most important ways a healthcare organization can accomplish these goals is to focus on ensuring claims are filed expediently and accurately while still ensuring patient privacy.
The challenge in doing this effectively is often related to poor visibility of the patient's health history. A patient can interact with a healthcare provider in many ways: the family doctor, specialists, walk-in clinics and emergency rooms. How does a claims administrator make the right decision when processing a claim when all the information on the patient may not be available to them? Even when electronic medical records have been implemented, we still have to ensure that all data is sent to a central database and made rapidly available as patient history to the team processing claims.
An approach to ensuring this information is available when needed is to implement real-time monitoring of the applications transmitting EMRs and of claims processing, itself. This can be problematic. The applications used by the various providers were built by disparate vendors, who were not focused on consolidation and claims processing enrichment. But the important goal is to safeguard patient privacy, remain HIPAA compliant and reduce the mean-time-to-know (MTTK) about problems that might impact the applications involved in these transactions.
While accomplishing this goal seems straight forward, it can be more complex than expected. The monitoring that is implemented must have several characteristics in order to be helpful. These should include:
- Real-time monitoring of the applications streaming patient data
- The ability to keep up with the constant high volume of data sent, and
- Real-time analytics.
The analytics will continuously look for patterns in the multiple data streams with an ability to find anomalies that infer actual or potential breaches in responsibility or non-compliance. Real-time analytics across multiple applications provide a big advantage to the Information Technology team. Early warning about problems helps keep support costs low, and the right IT specialist can be armed with appropriate information and insight to begin remediation of a problem as fast as possible.
One health insurer I know provides electronic patient information across all plans it provides. Medical records are automatically matched to the appropriate claim as they are received. This information becomes available to claims processing in real-time. Real-time availability eliminates the delay in waiting for faxed or mailed records and removes delays associated with research to match claims to medical records. This also provides improved accountability as all transactions are tracked and monitored. When claims are adjudicated, the processor has the necessary information to make the best decision for the patient without incurring additional costs to research the necessary supporting data. This reduces administrative costs and errors, provides accurate patient information and enables faster processing of claims.
This insurer monitors in real-time the patient data coming from providers and has real-time visibility across all internal applications including EMR, plan integrations, claims, claims appeal and others. It then captures the payloads of application messages in order to track and correlate them into a visualized representation of the business process flow.
The insurer knew it had a problem prior to implementing this level of real-time monitoring and analytics, but required a war room meeting to discuss what to do and who should do it. The company now knows who to involve and can provide them with consolidated visibility into the issue's details, what the request was, the servers involved, the timing and the data in the payload. This has helped the organization substantially in adhering to its SLAs. As a result it is able to improve the quality of care patients get and, at the same time, maintain lower costs.