Payers Add a Perk

Managing claims online is just the start as payers retool their Web sites to relieve practices' administrative burdens.

Days before patients arrive at Orthopedic & Sports Medicine Associates of Raleigh, N.C., the office staff knows which ones need to update their addresses, whose insurance is outdated, and who owes them money. And it's all done with a click of a mouse and a tap on the keyboard. The staff reviews patient data on Web sites offered by payers, who are increasingly trying to make working with them easier for physician offices.

Because ineligibility is among the top reasons for claims denials, you'd expect this intense scrutiny by the practice to pay off. And it has: while the average practice has a claims denial rate of 10 percent or more, this four-physician group has an enviable denial rate of 2 percent.

The physicians are doing well by other measures, too. "We are hitting between 30 and 36 days in accounts receivable," says Chris Adkins, the practice administrator. This is far better than their peers: the Medical Group Management Association (MGMA) put the 2004 median for orthopedic practices at 57 days.

While it would be inaccurate to attribute all of the practice's success to the use of Web sites, Adkins is convinced that it is key.

"We try to check as much as we can in advance. There is a lot of information available ... the Web sites are easy to access," he says, adding that his staff even attended Web training offered by Blue Cross Blue Shield of North Carolina.

"Easy" and "helpful" are words that haven't always applied to the Internet and payer Web sites. Slow dial-up service, a dearth of office computers, and health plan sites loaded with little more than hype kept users away.

Today, however, Adkins' medical group and others are making effective - and aggressive - use of Web sites to check their patients' benefits, as well as other transactions. The results, they say, are quicker payments and fewer denials.

Booming Web business

Many payers are working hard to encourage providers and their office staff to use their sites. They are updating pages, adding new features, and are keenly aware of what their competitors offer. Most require users to register with a unique name and password. Once done, the user has access to a series of services that can be accessed through secure technology.

"The use of the Web site has grown pretty phenomenally over the last couple of years," says Bridget Riven, Aetna's head of provider e-services.

Riven says two-thirds of the registered nonconsumer users of Aetna's Web site are office staff, while one third are physicians. "Our goal is to have about half of our providers registered by the end of the year," she says. "We are making progress. We have doubled the number of folks registered in the past year."

United Healthcare (UHC) appears to have already beaten that goal. Its Web site went live in July 2001 and now has 460,000 nonconsumer users who access the site on a daily basis, according to Anita Bachman, UHC's vice president for network business solutions. That number includes physicians, office staff, vendors, hospitals, and other providers.

In June, the site set a company record of 5 million transactions completed through the site; transactions have been growing by about 5 percent per month.

"We see about 23 million transactions coming to us on a monthly basis," Bachman says. "We want to continue to grow that."

Initially, payers concentrated their efforts on creating online tools to help offices review patients' coverage and benefits information, and to check the status of claims. On some of the largest payer sites, a transaction as basic as claims

submission only recently became available.

Access to payers' 'secrets'

Adkins and Judy Garard typify the common user of payer Web sites. Garard has been in healthcare for more than two decades, as a nurse and now as clinical operations specialist for Central Ohio Primary Care Physicians, Inc., a large medical group in Westerville, Ohio.

When she has a question about something payer-related, her first thought now is to go to the payer's Web site for an answer, rather than picking up the phone. She and members of her staff regularly visit the Web sites of the group's primary payers, mostly to check patient eligibility as well as review medical necessity criteria.

To help offices figure out what services or procedures might not be covered, Cigna, for one, lists about 500 procedures and their coverage status on its site, says Andrea Gelzer, MD, vice president of medical strategy and health policy for Cigna.

"Before, it was a secret," Garard says. "You had to ask for it, and a paper copy would come and it would have changed before you even got it - and you wouldn't know that. This is a better way."

"What we are trying to do through our provider portal is provide transparency and as much administrative simplification as we can," says Gelzer, echoing a sentiment expressed by other payers.

Like most payers, Aetna began its online presence by simply providing information but now is aggressively adding services and interactive features due in part to feedback from physicians and their staff, says Riven.

"Over the last two years we have focused on adding the capability to do transactions," such as checking claims status and verifying eligibility, Riven says.

Aetna's goal is to provide "eligibility information at the point of care." On the site, the user can determine not only if a patient is a current Aetna member, but also learn how much of a particular benefit - say, physical therapy and mental health visits - that member has used, to accurately price the copay and to bill for that service.

If a member exceeds the number of visits for which there is coverage, the physician could still perform the service - but the patient might have to pay out of pocket. That's the kind of information you need to have before you treat patients - and to communicate to them.

Going beyond the basics

The smaller, regional payers may not offer as many options on their sites as the national plans do. But the fact remains that the technology does exist to perform a variety of functions, so it may simply be a matter of time before the options are standard across all payer sites.

The most sophisticated sites offer recredentialing and claims resubmission through their sites. Some even post offices' fee schedules.

Several payers have also added a feature that allows offices to input codes and see what the range of payment would be; several codes can also be bundled and the system will produce an estimated payment for that coding combination.

The United Healthcare site may soon set a new standard for all payer sites. Just as some airlines' Web sites allow users to search for flights on that airline as well as competitors', UHC has made it possible to conduct transactions with all the major payers from its own site through what it is calling an "all-payer gateway," expected to be available by the end of this year. By signing up on the UHC site, practices could actually send claims and other transactions to Aetna, for example.

"From a technology perspective it took considerable coordinating and integrating between our systems and the three clearinghouses we were working with," Bachman says. UHC also worked hard to ensure the transactions would be secure.

Streamlining patient records

What payer Web sites currently lack is patients' medical information. Yet there is a growing sense that access to that information, especially if it can be shared among treatment providers, is a key to improving care and reducing medical errors, such as those caused by drug interactions.

Consumers, meantime, are showing a greater interest in putting their own medical information in an accessible electronic format - as long as the security and confidentiality of the data can be maintained.

These two forces are converging as medical groups and others are working diligently to craft the core of an electronic medical record that could traverse the patient-provider universe.

The Center for Information Technology of the American Academy of Family Physicians is helping to spearhead this effort, through a project called the "Continuity of Care Record." This is a core set of data elements that would be found in every electronic health record, whether maintained by a physician, patient, or payer.

The CCR would contain a summary of a patient's health information, including age, sex, insurance information, diagnoses, problem list, and medications used.

"It has about 80 percent of what you need to take care of a patient if they came to your office unconscious or just showed up," says David Kibbe, a family physician and director of the center.

Draft standards for the CCR are expected to be completed and sent to information technology vendors late this year. Several payers are participating in this initiative, and all indicate they are supportive of making clinical information available to providers.

"We envision it being a phased-in approach" with data from multiple points being brought together gradually, says UHC's Bachman. "Over time you get a total electronic health record."

Cigna's Gelzer believes clinical information will be available on the site eventually, but not until "we have an interoperative healthcare record. I think we are talking five to 10 years from now."

For now, office staff who love the Web are happy with what they can do. Garard thinks more of her own staff could benefit from her experiences. "The people in the trenches don't think they have the time to go and look [on the Web], and maybe they are not comfortable with the technology."

And Adkins' staff hasn't given up using the phone, especially when big bucks are at stake, such as with surgeries. "We call to precertify every surgery, even if we know for a fact it is covered. We still call."

Theresa Defino, editor for Physicians Practice, can be reached at tdefino@physicianspractice.com.

This article originally appeared in the October 2005 issue of Physicians Practice.