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Improving Claims Filing for Better Patient Care and Operating Efficiency
By Charles Rich

Health care organizations have a fundamental obligation to ensure that patients get the best possible care. No matter what type of treatment they deliver, health care providers also must ensure that they operate efficiently, whether in a nonprofit or for-profit setting.

One of the best ways to meet both of these objectives is to file claims rapidly and accurately while protecting patient privacy. It can be a complicated and challenging process, but today, providers are using technology to improve the effectiveness of patient care through online access to consolidated patient history.

Today’s technology enables a reduction in complexity and streamlines the capture, warehousing, and transmission of patient data across multiple, interconnected health care organizations. This enables providers to deliver the best care possible knowing the patient’s provider interactions across walk-in clinics, specialists, and the emergency department.

At the same time, the availability of these data during claims processing ensures greater accuracy in benefit determination and faster payouts. One of the primary challenges health care providers face when handling claims is a lack of access to patients’ health history. Patients interact with multiple providers across the care continuum, including primary care, specialties, emergency departments, and walk-in clinics. To maximize revenue, health care organizations must provide payers with complete information when they file initial claims, but they may not have access to all the data they need.

To address that problem and get a more complete picture of their patients’ health care history for treatment needs, more providers than ever are moving from paper-based records to EMRs. But even with EMRs, providers still must ensure that all data, centralized and accessible as patient history, are sent to claims processors.

One way to ensure the availability of these data is to implement a solution that monitors in real time the applications that transmit EMRs as well as claim processing activities on the insurer side. Since providers and payers use applications developed by a variety of vendors—applications that are not necessarily interoperable or designed with claims processing enrichment in mind—this can be a challenge.

The ideal approach to facilitate efficient management of electronic records and revenue cycles is a message and transaction-monitoring strategy that accommodates increasingly high volumes of electronic patient information. To fully benefit from this solution, health care organizations must design processes that help them ensure compliance with HIPAA regulations by keeping patient data secure during transmission and cutting the mean time to know (the amount of time required to identify problems that may affect the applications involved in data transactions). An effective transaction-monitoring strategy must provide the following:

• real-time monitoring of all middleware and applications that stream patient data;

• the capacity to accommodate high volumes of data; and

• real-time analytics capabilities to detect potential problems before there is an impact and to avoid false alarms.

This approach can enable health care organizations to analyze an extremely high volume of data—millions of messages per second—to gather all the information that is transmitted between various health care systems. By doing so, health care organizations can spot trends and identify unusual charges, which can allow them to proactively address potential problems with compliance or care delivery. An ideal performance management solution of this type enables IT teams to warn users about potential problems before they require costly manual intervention in order to secure payment.

A health care organization’s first obligation is to provide quality care to patients. Health care providers also must find a way to efficiently track and manage care and secure timely reimbursement. New technology solutions can help providers fulfill their obligations to patients and improve profitability and compliance by delivering data and monitoring tools that improve accountability across the care delivery and claims administration process.

Health care organizations are on the front lines when it comes to filing claims and ensuring compliance. With a solution in place that allows them to monitor message flows and transactions and apply the latest data, health care providers can make sure they give the best possible care to their patients, file claims correctly the first time, avoid incurring the costs involved in researching denied claims, and reduce administrative errors. A proactive strategy backed by the right technology solution can help health care organizations serve patients better while operating more efficiently.

— Charles Rich is vice president of product management at Nastel Technologies, a New York-based company that provides middleware-centric application performance management solutions.