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An EHR isn’t enough: Information Exchange for Meaningful Use

The Availity Perspective

Paul Adams

Director of Clinical Solutions

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Availity Health Information Network

Single Web Portal Consistent InterfaceReal-Time Information Between Care Providers & Health Plans

>65,000Physician Offices

>1,000Hospitals >400

Vendor Partners

- Clearinghouses

- Practice Management

Systems

- Hospital Information

Systems (HIS)

- Electronic Medical

Record (EMR) Systems

>150Direct Payers

>1,150Indirect Payers

>455,000Employers

>70,000,000Members

Availity® Health Information

Network

Business SolutionsClinical Solutions

More than 700 million annual transactions

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Availity—National Health Information Network

WA

OR

ID

MT

WY

CA

NV

UT

AZNM

CO

OK

TXLA

AR

MS AL GA

FL

SC

NC

TN

MOKS

NE

IA

IL INOH

KY

VAWV

PA

MI

WI

MN

SD

ND

NY

NH

VT

ME

MA

CN RI

NJ

DEMD

AK

HI

CA

Network Strength• 700M+ administrative, financial and

clinical transactions annually

• 50,000+ physician sites

• 1,000+ hospitals

• 400+ vendor partners

• ~1,300 payers (private and public)

Public/Private Collaboration• AHCA (FL Medicaid)

• HIE Demonstration Project

• Virginia Healthcare Exchange Network (VHEN) Portal

• AHIP Multi-payer Portal, Ohio

• Oregon Medicaid

• Florida Portal to CMS

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Availity Solution Principles

• Standard transactions at no or minimal cost to providers

– Receive payment from partners (e.g., payers)

– Optional value-added services are offered to providers for a charge

• Administrative, financial, and clinical information exchange on a regional basis

• Web, business to business (B2B), and electronic data interchange (EDI) transaction options

• Federated, real-time data model

• Supports HIPAA compliance and industry standards, e.g. ASC X12 and Continuity of Care Record (CCR)

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Technology Adoption is Critical Issue for Reform

Four key factors will accelerate the adoption of time-saving, money-saving and life-saving tools by care providers:

1. Providers want one place to access the majority of the information required to operate their business, to minimize the time they spend getting to the source.

2. Information must be presented in a common, consistent format, so it’s predictable.

3. Information must be current and accurate— true “decision-quality” information.

4. Access must be quick and easy to be most useful.

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Clinical & Business Information

• Treating a patient is only one aspect of modern health care delivery—behind every doctor or hospital is a business that has to run well, too.

• Being able to collect payment is essential to staying in business.

• With an estimated annual $60 billion in consumer bad debt to providers, health care providers must be afforded real-time access to information that tells them how much a patient owes.

• Already proven that it’s valuable for providers to get real-time electronic eligibility and benefits information, check on the status of claims, and estimate patient expenses.

Two Sides of the Same Coin

Certification Criteria

Proposed Meaningful Use Stage 1 Objectives: # 15

• Check insurance eligibility electronically from public and private payers.– Enable a user to electronically record and display patients’ insurance eligibility, and

submit insurance eligibility queries to public or private payers and receive an eligibility response in accordance with the applicable HIPAA transaction standards as required by law.

– Insurance eligibility checked electronically for at least 80% of all unique patients seen by the eligible Physician

Proposed Meaningful Use Stage 1 Objectives: # 16

• Submit claims electronically to public and private payers.– Enable a user to electronically submit claims to public or private payers in

accordance with the applicable HIPAA transaction standards as required by law– At least 80% of all claims filed electronically by the eligible Physician

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Jill uses the office practice management system, which is integrated with Availity, to find a date/time for Mr. Davis to come in.

On Wednesday, Jill checks eligibility and benefits on all patients scheduled for visits the next day.

The results of Mr. Davis’ E&B show he is an active member with Humana, is covered by a HDHP, and has $150 remaining on his deductible.

She then runs a CareCost Estimator to determine Mr. Davis’ expected financial responsibility for the visit. The amount comes to $195.00.

Mr. Davis contacts his physician’s office on Monday for an appointment regarding a persistent cough.

He is connected with Jill from the appointment desk.

He will see the doctor in three days,

on Thursday at 2 p.m.

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Jill calls Mr. Davis to confirm his appointment and to review the estimated cost for his visit and provide information on the practice’s payment options.

On Thursday, Mr. Davis arrives for his appointment and checks in by swiping his Humana member ID card through a POS device that is integrated with the office PMS system.

Mr. Davis is directed to an exam room where he sees his physician, Dr. Lewis.

Dr. Lewis accesses Mr. Davis’ EHR (integrated with Availity).

Based on the information provided, Dr. Lewis is able to view a recent chest x-ray Mr. Davis had taken a week ago at an urgent care clinic. Based on the EHR information, Mr. Davis’ symptoms, and the exam, Dr. Lewis orders a series of blood tests.

Mr. Davis is directed to the lab for his blood draw and told to expect the results in 24 hours.

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Mr. Davis leaves the exam room and stops at the check-out desk. He is advised that he will be billed separately for the lab services he received.

The clerk swipes the HSA card through the Availity card reader and collects the payment using CareCollect.

Humana submits its $45 payment to the practice via EFT.

Mr. Davis has enough in his HSA to cover the cost and presents his HSA card to the clerk.

The clerk submits Mr. Davis’ claim in real-time to Humana. In seconds the claim is adjudicated and the amount payable is $195.00, as estimated. Mr. Davis’ financial responsibility is $150.00 – the amount remaining on his deductible. Humana will cover $45.00.

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Improving Outcomes and Reducing Costs

AdministrativeBusiness tools improve workflow and enhance the efficiency of the visit.

Batch/Clearinghouse Claims Remittance AdviceReal-timeEligibility & BenefitsClaim StatusReferrals / Auth’sClaim SubmissionCard SwipeCareRead®

Clinical Clinical tools

support more informed

decisions and enhance the health of the

patient.

Health Record CareProfile®

Electronic PrescribingCarePrescribe®

Financial Financial tools reduce costs and improve payment recovery.

Patient ResponsibilityEstimatorCareCost EstimatorSM

Payment SolutionCareCollect®

Across the continuum of care, Availity eases your workflow

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Contact

P.O. Box 550857Jacksonville, FL 32255-0857904.470.4900

800.AVAILITY

www.availity.com

P.O. Box 833905Richardson, TX 75083-3905972.383.6300