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.”
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.