Digital Exchange and Processing of Medical Documentation Key To Success In Value-Based Care

By John Harrison, chief commercial officer, Concord Technologies.

John Harrison

With the shift towards value-based care reimbursement models, it has become even more important for providers to be able to digitally share patient clinical documentation with payers and other providers in a timely and reliable manner. Yet, despite administrative functions backing clinical care provision, both providers and payers have not actively explored new technologies to streamline and improve data exchange and processing workflows.

Manual, error prone document exchange methods plague healthcare. Fax is the most common secure communications protocol that providers use to electronically transmit patient documentation to health plans and other care facilities, leaving the recipient with a paper document that needs to be processed manually. Other methods of information exchange are available, but healthcare organizations often feel they don’t have a good, reliable alternative to paper-based faxing due to, in part, familiarity and comfort level with the technology.

When providers communicate the medical necessity of services to commercial health plans and government payers, they must do so within tight turnaround times. Failure to meet the submission deadlines can result in care delays for patients as well as denial or reduction in payment to providers. Additionally, comprehensive and timely communication is vital when executing proper transitions of care, where key patient information has to be part of the referral process to ensure optimal clinical outcomes.

Payers, on the other hand, spend hundreds of labor hours processing documents. CAQH CORE gives an example of a plan needing 792 labor hours, the equivalent of nearly 20 people working full-time, to process the attachments it receives by mail, fax and web portal in the course of just one week, presenting an enormous administrative burden. Only 6% of medical document attachments are processed using a fully electronic method. If all paperwork were processed electronically, the healthcare industry per-transaction costs could be reduced by over 60%, according to CAQH CORE.

Digitizing exchange and processing of medical documentation with the evolved fax and document processing tools can deliver numerous benefits to all healthcare stakeholders. Cutting down on manual document handling will ensure care is being delivered quickly and providers are adequately reimbursed. Payers can improve operational efficiency and handle claims and medical documentation faster.

Additionally, a more streamlined, electronic medical attachments exchange among payers and providers is the right step toward interoperability today because it will help break the data silos of separate clinical and administrative systems. The fluid exchange of clinical documents needed for claims adjudication, prior authorization and quality measure reporting is essential for value-based payment success. It could facilitate earlier identification of patient risk factors, reduce the time and effort associated with quality measure reporting and ease the adjudication of value-based payments.

Barriers to digitized exchange and processing of medical attachments abound and are well-documented: from the lack of federal standard for data exchange to differing workflows within every organization. At the same time, every organization can tackle the “paper challenge”: reducing or eliminating paper-based faxes which require heavy manual intervention to turn them into a digital format and route to the appropriate department.

Digitizing and streamlining paper-based workflows does not require a capital investment to overhaul the entire existing health IT infrastructure. By swapping their existing fax numbers to a cloud-based digital fax platform, both providers and payers can retire traditional fax machines, enabling them to move from paper to HIPAA-compliant, secure, point-to-point paths for exchanging data, streamline processes and save time.

As the next step, augmenting the digitized information exchange approach with artificial intelligence (AI) document automation technology can result in further benefits. AI and natural language processing techniques can identify and extract crucial information within the document required to process a prior authorization, a referral or any other document type.

This data includes patient name, medical record number, date of birth, as well as physician name, national provider identifier, and date of service. Extracting this data automatically decreases the amount of manual indexing necessary to triage the document to the correct system or team, such as clinical, financial or administrative.

By mostly automating the process of receiving, reading, classifying and triaging documents, organizations can save time and ensure information is not lost or misfiled but is processed faster by the correct person. Accomplishing this goal will mean that manual entry and human error can be reduced significantly, if not eliminated altogether. The information contained in outbound and inbound documents can be prioritized, addressed, processed, and delivered appropriately, speeding clinical and administrative processes.

In light of the COVID-19 pandemic, a fully digitized document processing workflow allows for a more flexible and safer work environments. Many healthcare administrators cannot currently work remotely as they do not have fax machines at home, especially fax machines routed to the hospital’s number, to handle documents as they typically do.

A seamless 100%-digital exchange of patient information is a must-have as the industry continues to pursue value-based care. The approach will facilitate fast and accurate decision-making by reducing a taxing and costly administrative burden of information exchange for both providers and payers. This is particularly timely now as the industry adjusts for the operational changes prompted by COVID-19 and prepares for pandemic developments that might come in the fall.


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