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Julie Miller was the former Managed Healthcare Executive Editor in Chief until May of 2014.
Eight Ohio health plans are participating in a pilot to streamline administration with hopes that national efforts could come next
The plans, which represent 91% of Ohio's privately insured lives, are feeding real-time transaction information into an aggregate Web portal similarly to the way airlines and hotels feed information into the travel Web site. Availity-the EDI clearinghouse and electronic information network created in 2001 by Blue Cross Blue Shield of Florida and Humana-hosts the interface and promises a standardized presentation of information and a simplified process for physician offices interacting with the plans.
The goal of the multi-payer site is to begin the first steps toward administrative streamlining on a large scale. Eligibility, referrals, claim submission and claim-status query transactions are presented in one place, saving staff the hassles of navigating multiple provider portals or making phone calls.
New Jersey healthcare stakeholders will host another pilot by the end of the year.
Ohio's plans (Aetna, Anthem, CIGNA, Humana, Kaiser Permanente, Medical Mutual of Ohio, UnitedHealthcare and WellCare Health Plans) are hoping to reduce the total number of transactions-especially manual transactions, which can cost $4 to $8 each. Organizers anticipate billions in long-term savings for the system overall.
"One of the top reasons claims get rejected is because duplicates are filed," Pisano told me. "Often, the office staff has difficulty determining what the status of a claim is, and what they have done traditionally is file a second claim. A lot of systems are designed so that if two claims are filed for the same service, both of them get kicked out. So rather than advance the process, it mucks the process up."
The multi-payer portal will offer the ability to check claim status and head off that wasted second (or third or fourth) claim.
REDUCING THE MUCK IN REAL TIME
Providing more specific transactional information, such as members' deductible balances, in real time at the point of care is possible in the portal, but not all plans are equipped to feed that data just yet. Pisano says more functionality will become available as time goes on.
Participating plans pay for the opportunity to be in the portal, but the service is free to providers. Sources did not provide the actual pricing or financial relationship between Availity and the plans but noted plans would realize administrative savings from the investment.
Availity will recruit providers to participate, and five Ohio physician organizations are also supporting the pilot by encouraging their members to get onboard. The only way the portal will have a noticeable effect on simplifying administration is if a critical mass of payers and providers sign on.
"Because of the way this has been done, because it has the support of the physician community in Ohio, we can expect to see some good uptake," Pisano says.
Julie Miller is editor-in-chief of MANAGED HEALTHCARE EXECUTIVE. She can be reached at firstname.lastname@example.org