Provider portals need streamlining

HEALTH PLANS are increasingly switching from their own Web portals to multipayer portals that enable physician offices and hospitals to interface with them more easily. But whether single-brand or multipayer, provider-facing portals must offer the functions that save providers time and expense.

If health plans make administrative tasks easier, providers can spend more time with patients and less time with paperwork distractions. An Institute of Medicine report released in September 2012 calculated that about 30% of health spending is attributed to waste and some of that waste came from excessive administrative tasks.

Multipayer platforms level the playing field for insurers, extending their reach to a large cross section of the provider community and improving their chances of competing in certain markets, says Jay Eisenstock, Aetna’s head of Provider eSolutions. For example, Availity, founded by Humana and Florida Blue in 2001, now serves 1,300 health plans.

Portals should offer providers key functions:

1 Real-time E&B

Interactions between payer portals and providers often start with real-time verification of a member’s eligibility and benefits (E&B). Under operating rules mandated by the Patient Protection and Affordable Care Act (PPACA), as of January 1, 2013, information included in E&B responses to doctors’ inquiries must be consistent across all health plans.

This includes what a member’s deductible is, the amount of his deductible balance and procedures and medications explicitly not covered by his health plan.

2 Real-time adjudication

An easy-to-navigate claims management system is essential. Real-time claims adjudication tells a provider within seconds how much the payer will cover and what the patient owes, allowing collection from the patient at the point of care. Also helpful is a searchable explanation of benefits tool that offers the patient’s claims history.

“It gives them flexibility to get information without getting on the phone with the health plan,” says Eisenstock.

A portal’s claim submission system should give a physician’s office the choice of submitting claims individually or through an online batch management system. The batch system can aggregate hundreds of transactions for a variety of health plans, route them appropriately and compile payers’ responses in a report that is sent back to the provider.

Real-time claims adjudication is not as useful to hospitals, says Mark Smithson, Humana’s vice president of provider process and network operations. Hospitals often need several days to itemize charges from different departments such as pharmacy, lab and operating room.

“No hospital is set up to accumulate that at the push of a button,” he says.

As patients’ liabilities rise with more consumer-directed health plans that carry high deductibles, real-time adjudication will be essential for practices. Patient financial responsibilities are less predictable than the traditional $20 copay, Smithson says.

 “The minute a patient leaves the office, the likelihood of collecting that patient [financial] responsibility goes down dramatically,” he says.

3 Claims alerts

Portals should offer a claims editing tool that alerts a physician’s office of a simple transactional issue, for example, when a particular data field has not been completed. Something as simple as forgetting to fill in a member’s date of birth would prevent a claim from being processed. Allowing staff to correct oversights right away will ensure faster processing and less chance of costly manual handling of the claim.

4 Referrals & authorizations

Portals need to make referrals and authorizations easier for providers. By prepopulating as much information as possible, such a feature can save provider staff time and prevent data-entry errors.

“A lot of procedures requiring authorization are based on specialty, so rather than having to go through a laundry list of procedures, it’s tailored to the kind of medicine that doctor does,” says Eisenstock.

Aetna uses a third-party platform that includes prepopulated data. For example, if a primary care physician refers to a certain cardiologist frequently, that provider’s information might be available as a drop-down or preselected field, Eisenstock says.

Physicians also want to obtain real-time prior authorization for prescriptions online.

“Typically it’s used for oncology drugs that are very expensive,” says Eisenstock. Besides eliminating a lot of paperwork, “there’s a decision logic functionality built into the tool that pulls up the right kind of form and the right kinds of pre-populated answers. When it comes back to the health plan, it’s got exactly what they need to evaluate the request so it eliminates phone calls back and forth.”

5 Clinical data

While E&B and claims management are at the core of provider portals, demand for clinical functions is also growing. A member profile that sources wide-ranging information collected from physicians, pharmacies and labs can provide a consolidated view of a patient’s healthcare service history across providers.

A portal’s clinical functions can be even more valuable to hospitals than physician’s offices. An emergency room doctor generally has no idea of a patient’s medical history, including drug allergies, says Smithson at Humana.

Eisenstock sees growing demand among health plans and physicians’ offices for capabilities that alert providers to gaps in care. By sending an alert when a physician prescribes a new drug, a gaps in care tool can flag potential drug interactions, for example. Care alerts might also tell a physician that it’s time for a diabetic patient’s eye or foot exam, or to consider lipid panel testing.

However, portals need to be able to customize and streamline care alerts according to a provider’s needs.

“We wouldn’t alert the need for a mammogram to a podiatrist,” says Smithson. “We also filter for the most critical alerts so informational only alerts would be less likely to be shown if a more actionable alert needs to be delivered.”

NovaHealth, a multispecialty medical practice in Cumberland County, Maine, does not use care alerts because of the excessive volume of them, according to Anne Hindley, operations manager.

“We’d like to see a way to turn off alerts that we don’t see making any difference in patient care,” she says.

An estimated 80% of the interactions between providers and health plans are transaction-oriented, according to John Jesser, vice president of WellPoint’s provider engagement strategy.

“If we can make those [more basic] need functions less expensive and more efficient, we can get the doctor’s attention to talk about higher level functions like diabetes care and patient-centered medical homes,” he says.  MHE