When it comes to obtaining accurate clinical data to certify a claim, the process is fairly straightforward – that is, until it’s not. Siloed processes, poor data quality, coding errors, data entry mistakes, and political considerations are among the common barriers the industry must address.
To remain competitive, payers need fast access to clinical data along with the ability to manage and optimize it for use. In accordance with the Cures Act, payers are required to give members access to their healthcare data using the Fast Healthcare Interoperability Resources (FHIR) standard. The mandate does not, however, facilitate interoperability between payers and providers — and many payers lack the expertise needed to transform raw data into actionable insights.
The claims process starts when a provider sends a claim or prior authorization request to a payer. Payers can then respond in one of two ways — they can either approve and reimburse the claim or deny it because it’s not covered under the patient’s health plan.
In the process of providing prior authorization or approval for a claim, payers typically reach out to providers to request evidence in the form of an image, scan, lab result, or other attachable documentation. Commercial health plans and government payers like Medicare and Medicaid are required to read attachments in order to process payments for certain procedures. Electronic claims attachments are additional documents that go along with a medical claim that don’t fit into the constraints of the claim itself. Attachments provide supplemental information the claims processor will use in processing the claim. These may include operative and discharge summary forms associated with a procedure claim, a Certificate of Medical Necessity, and so forth.
Until recently, these communications were handled manually through the mail or via fax. The Cures Act seeks to replace these clunky, redundant manual processes with clean, automated electronic (digital) methods. But despite the solid progress around electronic transactions in general, issues with authorizations and attachments persist, emphasizing the need to leverage streamlined, interoperable technologies whenever possible.
The process takes time, particularly if payers require multiple exchanges to obtain the information they need. If the provider sends the information manually, they don’t have a way of tying the information being sent to the appropriate claim. As a result, payers are often tasked with manually matching attachments to claims, increasing the potential for mistakes, claims denials, delays in reimbursement — even poor outcomes for patients. And because insurance carriers have different rules about attachments, providers often have trouble understanding when a claim requires them.
According to the 2020 CAQH Index Report, only 22% of medical health plans were receiving attachments in a fully electronic manner in 2020, up only 2% from 2019. In fact, despite the industry’s best efforts to integrate FHIR standards and continue promoting speed, accuracy, and interoperability, 8 out of 10 health plans still rely on fully manual processes to handle attachments.
To address these challenges, many organizations are trying to define an electronic standard for claims attachments transactions. This has been a hot topic in the industry for a while, but the Cures Act has created an added sense of urgency.
Verinovum is working with industry leaders to promote the adoption of FHIR standards and improve data quality across healthcare. Once the standards are adopted at scale, it will be much easier to understand how the industry can effectively communicate across all stakeholders. Considering the industry’s move from fee-for-service to value-based payment models, clinical information in claims and attachments is going to be extremely important for ensuring providers get compensated for optimal health outcomes.
Changing to a platform that supports electronic attachments does more than just streamline and speed up the claims process for payers and providers. It can also save money. In 2020, healthcare payers spent $590 million less on attachments overall than they did in 2019, according to the 2020 CAQH Index Report. At the same time, the costs associated with manual attachments increased.
If adoption of electronic attachments were at 100%, the industry could be saving as much as $377 million each year – plus the $147 million providers already save through electronic attachments. Although attachments represent a small share of medical transactions, reducing time and spending in this area should have a positive influence in shifting the industry towards electronic operations.