ACA Mandates Help Speed Up Shift to Sharing of Patient Information

Existing networks revamped to facilitate more collaborative -- – and cost-efficient – approach to healthcare

insurance claim computer
As the Affordable Care Act pushes insurance companies to change their relationships with doctors and hospitals, the billing arrangements they have with providers and the sprawling computer networks that enable them are slowly changing as well.

Some insurers, for example, are taking existing networks — which allow doctors’ offices to perform basic administrative tasks, such as checking a patient’s insurance benefits and claims — and gradually beginning to use them to support new models of medical care.

A doctor in one of the new programs might use such a network to let an insurer know that a patient’s blood pressure has been checked, and in return receive a payment for working to keep the patient healthy. That’s a change from the usual practice of a doctor billing for performing individual exams and procedures, regardless of how well the patient is doing overall. The goal is to improve patients’ health while trimming the growth of medical spending.

In New Jersey, insurance companies and other payers provide patient benefit information to doctors through a website built by NaviNet, a leading player in the health information technology field. Insurers can also customize the platform to remind doctors that a patient is due for a checkup, and some have recently begun tracking patient care to support the new generation of provider incentive programs.

Such uses represent an evolution from the traditional medical billing process, which consists largely of providers telling insurance companies or federal payers what work they have performed, and the insurers deciding whether the claims are allowed under a patient’s policy. Many doctors’ offices and hospitals have become expert at knowing which billing codes to use to maximize their earnings.

“Medical billing, that issue that used to exist before the Affordable Care Act, is slowly either dying or evolving,” said Naveen Rao, an analyst with Chilmark Research, which specializes in health information technology. “Before, it was like, how can we milk a Medicare reimbursement plan for the most? Let’s make sure we’re capturing every single thing we do, every visit, every lab test that we run to the lab, every prescription we’re issuing.”

“We’re in a little bit of a different world now,” Rao added. “People aren’t really worried about nickel-and-diming Medicare. They’re more worried about getting dinged because a patient showed up in the emergency room again even though they just got out of a surgery five days ago, or a patient shows up with complications of diabetes that could have been avoided pretty easily if they just took their statins.”

“Medical billing historically has been on a pretty much insane model, which is fee for service,” NaviNet CEO Frank Ingari said in an interview. “Fee for service is a euphemism for piecework. We had treated our clinicians as though they are factory workers building widgets and we pay on a volume basis for procedures performed.”

A multitude of networks

The health information technology industry has changed rapidly as the federal government has pushed hospitals and doctors to adopt electronic health records, or EHRs, instead of keeping track of patients with piles of paper in manila folders.

The federal government’s 2009 economic stimulus law created the federal HITECH Act, which set up a series of deadlines and incentives for Medicare providers to show they are making “meaningful use” of electronic records. Medicare will start assessing financial penalties in 2015 for those who have not met the benchmarks.

While the law has helped spur the industry’s growth, the health I.T. world that has developed is highly fractured.

There are many different EHR systems, various analytics offerings to interpret data, and an array of regional health information organizations— such as Jersey Health Connect and Camden Coalition — that give providers across a region access to that information. Nationally, these information networks have been created by private companies, nonprofits, government initiatives and provider networks, leading to a tangle of standards and systems that cannot communicate with each other.

On a parallel but separate track, Boston-based NaviNet and other vendors developed systems called clearinghouses for insurers to handle claims and communicate benefit information to their providers. Though they are not legally required, these clearinghouse systems have also proliferated, which means that insurers and medical office staffs have to be able to access a number of different platforms that transmit varying types of information.

Thomas Conklin, a director at Aetna’s Provider eSolutions unit, said that despite the wide adoption of NaviNet, the insurer still moves data over dozens of different systems.


“Currently, over 80 percent of our participating providers — that’s well over a million providers — are associated with a NaviNet office,” he said. “We have relationships with approximately 30 of the large (clearinghouse) vendors that you may be aware of, like your Availitys, Emdeons, McKessons, et cetera.”

It was only in 2010 that New Jersey’s major insurers arranged to give doctors access to benefits and claims information for all their patients through a single NaviNet website, rather than requiring them to use each company’s separate software platform or to depend on labor-intensive phone calls, faxes and mailings. The actual submission of claims still occurs through other systems.

Before adopting NaviNet, Horizon Blue Cross Blue Shield of New Jersey had doctors perform administrative transactions through a proprietary platform it set up in 2002, said James Dell’Arena, Horizon’s director of network services and strategy.

“NaviNet was becoming much more of a tool that was being heavily used by our physician community, because of the fact that they got additional (insurers) to work with them on their systems,” Dell’Arena said. “Our professional network was really looking for Horizon as the largest payer in New Jersey to go on NaviNet as well to conduct our transactions there.”

NaviNet says it is the broadest-reaching healthcare communication network in the United States. Thirty health insurance plans are on the network, along with more than 70 percent of clinicians’ offices and more than 4,000 hospitals, the company says. In 2012, as its importance to the healthcare system became increasingly apparent, NaviNet was acquired by three Blue Cross plans — Horizon, Highmark and Independence Blue Cross — and Lumeris, a health I.T. provider.

Moving into accountable care

Insurers say NaviNet and other clearinghouses provide several advantages. They speed up claims processing, so doctors can get an answer in a few days rather than a month; make referrals easier; facilitate electronic payments; save time and money by reducing paperwork and phone calls; help doctors understand new kinds of provider networks introduced under the Affordable Care Act; and make patients’ financial responsibilities clear at the time of their medical appointments.

By providing access to past claims, the networks give doctors and other healthcare workers a limited look at patients’ medical histories. Insurance companies can also do some basic analysis and suggest actions for doctors to take.

Using a patient’s claim data, Aetna creates a document called a “personal health record” and alerts the patient’s doctor to “potential wellness opportunities or safety risks,” which are accessed through NaviNet. AmeriHealth sends “patient-specific preventive care reminders” for services that are due or overdue. Last year, Horizon created a new feature that lets providers pull “care gap reports” detailing recommending screenings and services.

Horizon and other providers are also beginning to use the clearinghouses to support new care models encouraged by the Affordable Care Act: the Patient-Centered Medical Home, or PCMH, and the Accountable Care Organizations, or ACO.

In an ACO, a provider network takes responsibility for keeping patients healthy, especially those with chronic conditions. Beyond treating people at appointments, an ACO’s work extends to continuously tracking patients’ conditions, making sure they come in for checkups, visiting them at home if necessary, and coordinating care among different doctors, nurses and health workers. In a PCMH, a physician’s office takes on a similar role.

In both models, providers are paid for making sure that the patient meets certain goals, such as undergoing recommended screenings, staying out of the hospital after surgery and getting needed lab tests. Doctors use electronic medical records to store the volumes of patient data generated, and insurers use clearinghouses to manage the data and pay the doctors incentives for following patient care plans.


Horizon has set up a number of ACO and PCMH programs, including one in pediatrics. Dr. Jill Stoller, a partner at Chestnut Ridge Pediatrics and president and CEO of BCD Health Partners, said NaviNet hosts the care plans that are provided to parents of children in the PCMH program and to the insurance company.

“Children who have some sort of chronic medical condition, whether it’s diabetes or asthma or attention deficit disorder — we develop care plans for them. That’s a very simple written form that outlines for the parents what was done at the visit, what the plan is going forward, when their next appointment is, if they’re being referred to any specialists,” Stoller said.

“We need to enter the patient’s diagnosis, when we saw them, when we’re going to see them back. So it’s a way of Horizon keeping track of what the pediatricians are doing for this new pilot program, and there’s money that goes along with this. They’re incentivizing this to get done, because it’s improving care,” she said.

Horizon has also loaded all the manuals and information for the PCMH project into NaviNet for easy access, she said.

Stoller said the NaviNet system has been very helpful, though she noted its limitations. It can only be accessed on the Internet Explorer browser — not the popular Firefox, Safari or Chrome browsers — and thus can’t be used on Mac computers. The system goes down at times. Care plans are still initially written by hand, scanned, and uploaded through a different Horizon system before they appear in NaviNet.

And, as with clearinghouses and electronic health records generally, the system does not connect to the EHR system used by Stoller’s practice group.

“In the ideal world, we could be transmitting this information from our EHR directly to Horizon. But that inter-operability is just not there yet,” she said. “So that’s why you have to do these intermediary steps.”

Visions of convergence

Tying compensation to health outcomes through ACOs and similar models is widely described as the future of healthcare. Experts say that efforts to make medicine more efficient and less expensive will bring the roles of insurance companies and providers closer together, as insurers become more involved in managing care and doctors take on more financial risk.

But the technology needed to make the new models work is far from ubiquitous. Rao predicted that, even with the federal incentives for EHR adoption, it will take until the end of the decade and the retirements of many older physicians before all medical offices use electronic records. Only around 2020 will easily useable medical data start to be widely available, he said.

Making that data available digitally to any provider is another challenge, although in New Jersey officials say they will start a statewide health information network this year.

With so many different incompatible records systems currently in use, it is unclear when doctors will have access to a broad health information exchange, or HIE, that can easily pull records from elsewhere in New Jersey or from out of state.

However, as standardization and interoperability do gradually become a reality, clearinghouses like NaviNet stand to play a big role because they already have such a high level of penetration in doctors’ offices and play a central role in new reimbursement models that are expected to proliferate.

“We have a very complementary role to the HIE,” NaviNet’s Ingari said. “In fact, we’re working on connections — we’ve done this in other states — and we’re hoping very much in the state of New Jersey to be part of systems that connect HIEs to the NaviNet system, so that we integrate this reimbursement-oriented information with all the rich medical data in the HIE.”

“As we get to more population-management type models, bidirectional exchange of clinical information will become increasingly important, between payers, health insurance companies and providers, so that can we can assist in managing the populations,” Conklin said. “We’ve got all the data-crunchers on our side, the clinicians on the provider side can deliver the care, and networks can be the middle piece moving that information.”