SunGard has launched a technology solution to help health payers identify and mitigate fraud, waste and abuse in health insurance claims in an effort to reduce the cost of patient care. By linking a selected Health Information Exchange (HIE) to the health plan’s databases or processing systems, SunGard’s iWorks HIE Connectivity solution provides health plans with real-time access to critical information within patients’ electronic health records (EHRs). This can help reduce length of stay, duplicative procedures and readmissions, fraud, abuse and costs while helping improve the speed, quality and safety of care, particularly for chronically ill patients.
According to the U.S. Department of Health & Human Services, about 11.4 million consumers selected health insurance plans or were automatically re-enrolled through the HealthCare.gov platform or state-based marketplaces during the 2015 open enrollment period under the Affordable Care Act. As the number of insured individuals increases, and the number of Americans enrolling in Medicare grows each year, managing patient care and controlling medical costs will become more crucial to healthcare providers and health plans alike.
Today, health plans typically are notified of a patient admission and/or discharge from a healthcare facility 60 to 90 days later, once a claim is processed. This hampers care managers’ ability to proactively reach out to recently discharged members to ensure proper understanding of treatment and medications, which can lead to unnecessary readmissions. The delayed receipt of information can also lead to duplicative treatment if members do not share recent procedures with their primary care physicians (PCPs) proactively. In addition, most patient medical records are stored on paper.
HIEs standardize data to allow healthcare professionals and patients to access and share a patient’s vital medical information electronically with the goal of facilitating coordinated patient care. The current lack of interoperability between health systems, whose providers’ use multiple electronic medical record (EMR) systems, and health plans is impeding information flow and access to complete data which can place physicians, hospitals and health plans at a significant disadvantage. Bridging the gap between EMR software can help healthcare organizations deliver better outcomes at a lower cost.
SunGard’s iWorks HIE Connectivity solution provides health plans with an infrastructure to receive alerts on patient care activity, manage and analyze data, and coordinate workflow with care managers. It provides the data integration and information flows necessary to support new payment models and patient care standards.
“The demand for electronic HIEs is growing along with nationwide efforts to improve the quality, safety and efficiency of healthcare delivery. SunGard’s HIE Connectivity solution can play an important role in a health plan’s overall cost containment and customer service strategies, which will become more crucial as the number of individuals enrolling in health plans continues to grow.” – J.P. James, president of SunGard’s insurance business
About SunGard Financial Systems
SunGard Financial Systems provides mission-critical software and IT services to institutions in virtually every segment of the financial services industry. The primary purpose of these systems is to automate the many detailed processes associated with trading, managing investment portfolios and accounting for investment assets. These solutions address the processing requirements of a broad range of users within financial services, including asset managers, traders, custodians, compliance officers, treasurers, insurers, risk managers, hedge fund managers, plan administrators and clearing agents. In addition, we also provide professional services that focus on application implementation and integration of these solutions and on custom software development.
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