Greg Burgess, President and Chief Product Officer, spoke at the 2019 AHIP Institute & Expo on “The Path to Point-of-Service Payment Success.” Below is the first in a series that dives deeper into the advancements in technology that will bring us closer to accurate point-of-care payments in healthcare.
Imagine a patient is experiencing severe knee pain and requires surgery. Their mind starts to spin. How much does all this cost? Their doctor doesn’t know and directs them to their health plan. They find out they need preauthorization but are still not given a price. The unknown financial impact of this procedure only intensifies the pain they feel.
On the payer side, administrators face just as much anxiety and delay. They are waiting for the patient’s doctor to return a form that needs to be entered into the payer’s system for authorization. Every service type requires a different process. Benefits must be checked. Policy updates are pending. And they still can’t get accurate pricing for the patient.
Several calls ensue from both provider and patient to the plan administrators with questions about statements with confusing codes fraught with inaccuracy. A painfully long back-and-forth process follows over the next six months to resolve errors.
This story is too common today. Our healthcare process creates confusion and complexity from payer to provider, and eventually, to the patient. But what if patients could pay the correct amount for the care they receive with full transparency of fees the moment a healthcare professional renders service? This point-of-service payment success would be revolutionary in the healthcare industry. It would allow transparency between payers, providers, and patients, freeing time and energy to improve overall patient care.
Is it attainable? Yes, but we need a technological evolution to get there.
Is healthcare the only industry with this problem?
Technology is rapidly advancing what is possible, but big problems remain with how our industry manages data. Currently, health plans often rely on outdated systems, manual administrative tasks, and disjointed data, making payments inefficient and inaccurate. To accommodate this process, your organization likely has several disconnected systems that don’t work easily together. This fragmented method leads to issues of wasted time and resources that should — and can — be remedied.
It wasn’t long ago that that our everyday life was disjointed and fraught with inefficiencies. Navigating a car, taking pictures on your vacation, storing new phone numbers, and making calls required unique tools and had their own pain points. Now we can accomplish all this with one handheld tool – the smartphone.
As the smartphone unifies all these tools, the Internet makes it possible to unify our data. Today’s data isn’t stored in a phone book or on a camera roll — it funnels from device to device, connecting information in a real-time environment. Our technology continues to evolve and adapt, and all the resulting information is available to recall, share, and utilize at a moment’s notice.
For too long, payment management in the healthcare industry has mimicked the outdated patchwork model that forces us to rely on disparate solutions that increase, rather than relieve, the problem of inaccurate data. In our everyday lives, technological advancements have led to drastic changes in the way data is used and transmitted, so why is the healthcare industry still stuck in the past? We don’t have to be.
The technology that will allow us to achieve point-of-service payments exists today. Health plans can start to streamline the process and enable data that is current, actionable, and connected to everyday processes by leveraging the Internet through cloud-based delivery.
Data Delivery in Healthcare
Data is complex in all industries, but this is especially true in healthcare. From differences in medical formats and standards, to a multitude of code sets, to unreliable patient and claims history, data management is a huge challenge for healthcare providers. Add to that the frequency of updates to healthcare policies and regulations, and this magnifies the issue of keeping data accurate in payment management.
Traditional on-premise solutions rely on misaligned, manual, and infrequent data and policy updates. With this method, it can take months to implement an update, and these updates often occur several times each year and rely heavily on internal IT support.
In contrast, cloud-based payment delivery systems place your entire payment ecosystem on the Internet, allowing software and services to be updated in real time. According to the Advisory Board, 90% of claims denials (e.g., demographics and technical errors, duplicate claims or services, authorizations) could be prevented with real-time data. 1
Imagine how much more efficient and accurate our claims process would be if we removed denials by having accurate, real-time information at our fingertips.
Systems housed in the cloud offer frequent data updates delivered remotely, enabling you to always work with current information. The cloud system creates one place to manage all aspects of claims payments, while reducing IT maintenance delays, allowing rapid updates without using internal resources, and — crucial to point-of-service payments — delivering centralized and accurate data.
Accessible, Scalable and Secure Data
Regulated by data centers, data in the cloud is accessible 24/7 by you and any business partners you wish to grant access to, including vendors, consultants, and providers. This immediate accessibility eliminates delays common from reliance on internal IT and on-premise solutions. The cloud also offers redundancy: data housed in several secure locations to eliminate a single point of failure and reduce the number of delays caused by downtime.
The cloud has computing power that is highly scalable based on the demands of your organization (e.g., for spikes in claims volume) to improve processing time and efficiency. It has real-time accessibility to large amounts of data which makes your system processing better, allowing healthcare payers to take immediate action from a streamlined and integrated approach to payment management.
Recent advances in cloud-based delivery have made it more secure than on-premise solutions. Cloud system providers and the technology companies who use their services are obligated to abide by rigorous security and confidentiality standards (such as HITRUST certification) to handle protected health information (PHI) and sensitive data from payers and providers. Cloud-based providers deliver continuous monitoring, remediation, and patching to reduce dependence on your internal IT departments, freeing them to focus on high-value objectives like implementing analytics and business intelligence to enable better informed business decisions.
Point-of-Service Payment Accountability
On the path to point-of-service payments, we still have many obstacles to face. Change will not happen overnight, but the importance of leveraging data is clear, and we are making progress.
Think back to that confused and anxious patient and the administrator who was working on the cost of the claim. Who is responsible for fixing the system, reducing their anxiety, and improving overall care? We, the payers and technology providers in the healthcare industry, have the ability to create and drive this change and take the steps necessary to achieve point-of-service payment success.
For example, a cloud-based delivery system for a healthcare payer might look like this: An external technology vendor with expertise in healthcare policy reviews the numerous policy and CMS updates upon their release. The data is incorporated into a technology platform within a cloud environment. After testing, the new rules and policies are automatically uploaded into the system, putting them to use on or before their effective date.
This quick and seamless process is ideal to handle near daily CMS and policy updates. The data is accurate, and the different processes in the pricing system are all connected and can work in harmony to provide accurate pricing results the first time. It eliminates the waste we see from claims inaccuracy and inefficiency and gets us one step closer to enabling real-time data across the payment system.
With data in the cloud, we are laying the groundwork necessary for integrated ecosystems, automation, business intelligence, and many other advances that can save time and money for payers while moving us closer to a world of point-of-service payment accuracy.
Interested in reading more? Subscribe now to get the next in the series, “The Path to Point-of-Service Payment Success: Integrated Ecosystems” via email.
1 Advisory Board Company, An ounce of prevention pays off: 90% of denials are preventable, 2014, Published: 11 December 2014
Burgess is dedicated to improving healthcare payment operations through technology. We bring technology innovation and real-time data to an overlooked and critical part of the American healthcare system. Our scalable Payment Accountability® platform, Burgess Source®, integrates payer systems to transform payment workflows and provide powerful business intelligence to lift payer performance. The company is located in Alexandria, Va., with a satellite office in West Hartford, Conn., and online at burgessgroup.com.