By Joey Cavanaugh, RN, chief operations officer, Zotec Partners.
The American healthcare system has long been burdened by interoperability issues preventing easy access to and sharing of important patient health data. Amid the ongoing COVID-19 pandemic, those issues have created additional challenges for physicians, administrators, and other industry partners. If these problems persist, they could impact provider business models negatively.
Increased consolidation among physician groups during the pandemic has resulted in a corresponding increase in coding operations for many practices. Given the gap between the demand for coders and the trained talent available to meet that demand, organizations have increasingly shifted toward outsourcing to fill critical technical roles. The process of outsourcing these skills, combined with a surge in the number of labor hours needed to meet organizational objectives, could increase the time to code or decrease the quality of output, ultimately creating revenue cycle issues.
If not careful, staffing issues can cause fluctuations in data quality. With less personnel available to ensure the correct information is entered into the correct fields, some organizations have found it difficult to fully harness the power of healthcare solutions to streamline revenue management and operations. Moreover, understaffed facilities may struggle to make the changes to technologies and internal processes that would equip them to take advantage of government programs providing reimbursements for COVID patient care. New CPT codes for COVID have also required insurance companies to update their processes during the pandemic, adding complexities for providers in how quickly they can exchange medical information.
From a clinical perspective, the pandemic’s far-reaching impact on the healthcare system has manifested in the form of lost productivity, resource deprivation, HIPAA breaches, and other, often severe, consequences. However, the strain it has put on payers and revenue cycle management systems has been somewhat less visible from the public eye. In the concerted effort to support clinicians and mitigate the pandemic’s effects on frontline workers, the focus for getting the right data into the right hands to ensure services could be paid for in a timely manner was temporarily deprioritized. Unless these interoperability challenges are addressed as an industry, the cost of healthcare will continue to rise, as will the clunky experiences for both providers and patients.
Bridging the Gap
The issues caused and exposed by the pandemic tend to be cumulative in nature. If, for example, providers were already transmitting data automatically via secure electronic methods before the health crisis, it was easier for them to make the necessary changes after it arrived. If they were gathering and sending data manually, however, it was harder to suddenly pivot processes and systems and to make the necessary personnel and technology changes to support such a shift.
Providers were incentivized by the government to invest in electronic health records, and carriers began accepting only electronic data transmissions to improve their business performance. However, these policies and practices have left a gap between capturing patient information and sending it to carriers by implementing similar incentives for secure digital transmission. The benefits that come with digitizing medical records and EDI forms can’t be fully realized if transition data flowing from clinical databases to revenue cycle management and payment systems aren’t also addressed.
If policymakers could add incentives for providers to transmit data electronically, they could help reduce the risk of HIPAA violations and drive more efficiency throughout the entire system. In addition to removing the costs associated with the labor requirements inherent in this process, this effort would reduce denials and ensure patients get more accurate bills faster, ultimately reducing healthcare costs for everyone. It’s difficult for policymakers to have a handle on the vast industry knowledge needed to understand this, so it’s up to providers and their strategic revenue cycle partners to lead the transformation.
It benefits business leaders at healthcare practices to think long-term and prioritize investments in electronic coding technology and processes. The upfront expenses will pale in comparison to the savings associated with decreased labor requirements and the elimination of human error thanks to auto-coder and AI reading tools. It takes technical expertise and resources to implement these changes, but with the proper incentives, practice administrators and healthcare IT leaders can make the business case to invest in the revenue cycle solutions to drive this process transformation and bolster their teams’ ability to effect lasting change.
The Time to Act Is Now
If interoperability challenges aren’t addressed, the industry will be subject to more of the same. Providers will continue to be limited in their ability to reduce waste in the billing process and unable to minimize physician charge lag, human errors, denials, and write-offs in a way that could make a meaningful difference. Healthcare revenue will suffer, as delays in charge capture inevitably result in payment delays, and providers without consistent charge flows will have cash issues that impact all aspects of their operations. Moreover, hospital systems could continue to pass along poor-quality data as a result of human mistakes on the front end, exposing themselves — and potentially patients — to preventable risks.
The Health Information Technology for Economic and Clinical Health Act laid the groundwork for the industrywide move to electronic health records and created a data layer allowing for the introduction of new products and services into the healthcare technology ecosystem. Similar incentives aimed at improving the interoperability and transmission of electronic health billing data would enable the industry to build on that initial success. A failure to establish these incentives would ultimately threaten the long-term viability of provider business models.
With this in mind, it’s up to providers and strategic revenue cycle partners to take the lead in advocating for consistent standards that would allow for improved interoperability. Major electronic health record vendors should work to standardize data transmission, and the industry needs widespread adoption of Health Level 7 standards for managing, delivering, and assessing clinical services, which would help normalize IT best practices and safeguards. Providers that make moving to an HL7-based interface and adhering to these standards a top priority will potentially improve the overall patient billing experience (and their own financial performance) by eliminating friction from the billing process. In the end, that is a win for everyone.