By Mike Peresie, Sajid Khan, and Adam Sullivan
The ability for payers and providers to effectively exchange relevant and timely information is a key component in reliable and cost-effective healthcare delivery. Currently, this is a largely paper-driven process with the two parties using tools like fax machines, manual portal uploads, or even snail mail to send clinical documents back and forth.
In recent years, payers and providers have had the opportunity to start electronically exchanging these documents in the form of attachments—electronic renditions of medical documentation, such as X-rays, lab reports, or questionnaires. An attachment can be delivered in an unstructured format, such as a text file or PDF, or as an image in the form of a JPG or TIFF.
Despite the availability of electronic send options, many providers still rely on manual approaches. In 2017, for example, only 6% of the 100 million medical attachments submitted annually were sent electronically.[i] Although there has been some improvement since then, the industry has a long way to go.
The good news is that a shift is underway, with payers and providers beginning to embrace the use of ASC X12 275 transactions. The 275 standard allows attachments to be electronically sent either without a request from the receiver (called an unsolicited request) or in response to a request for supporting documentation. Although other data exchange standards like FHIR will probably do more in the long run to advance the industry toward full-scale interoperability, there is growing consensus that the 275 standard is a good stepping stone toward better information sharing because it’s available now and accessible via simple application programming interface (API) integrations. In addition, X12 275 can accommodate all kinds of document formats and send information in a way that’s dramatically more efficient than any of the manual processes. It easily costs providers six to eight times as much to submit via mail or another manual method as compared to a 275. It is estimated that moving to electronic medical attachment submission could help providers nationwide save $49 million each year.[ii]
While switching to 275 transactions can take some of the cost and inconvenience out of data exchange, the true innovation in healthcare comes when organizations take the next step. This involves moving toward an automated workflow that meets a number of payer use cases, such as claim processing, prior authorization, HEDIS, risk adjustment, payment integrity, and so on. A provider does a lot of work to submit attachments based on payer requests, and payers put in a similar degree of effort when they receive these documents. Each of these workstreams requires resources that have costs, and the burden of sending data back and forth can be significant.
For providers, having the ability to preemptively send information and not have to wait for a case to be loaded into the payer’s system is intriguing. And to have that capability embedded into existing workflow is even more appealing. Innovation in this area will lead to scenarios where attachments are automatically requested based on the existence of certain parameters, and then attachments are automatically submitted, driving a more efficient model of data sharing. By injecting disruptive technology into both sides of the equation to remove some of the manual and labor-intensive aspects, the industry can streamline the process of sending and receiving attachments and take additional costs out of the system.
While lack of automation in the sending and receiving functions is slowing information exchange, there is also a good deal of noise in the process that could be reduced. The overarching purpose of attachments is for providers to send information to payers and for them to review that information to make decisions about medical necessity and payment. Unfortunately, there are a lot of unnecessary attachments exchanged as part of this effort, which leads to inefficiencies on both the payer and provider sides. A data exchange solution that uses emerging technology, such as artificial intelligence or natural language processing, can proactively review and interpret an attachment’s content and determine its relevance before sending it. This ensures only the most appropriate attachments are exchanged, removing some of the burden from the adjudication process and making it more efficient and less costly.
To be effective, AI solutions require a large volume of data from which to uncover patterns and learn. When these solutions are able to review a sizeable number of medical charts and payer decisions, they can recreate decision-making processes to determine whether an attachment is germane to a payer request and valuable to include. And these solutions can conduct this review faster and often more accurately than humans. By using AI in this manner, organizations can further reduce the administrative overhead that makes information exchange so challenging.
The era of manually sending attachments is ending as organizations increasingly pursue electronic options. However, hospitals and health systems should not limit themselves to simply automating a cumbersome process. By leveraging disruptive technology to reimagine what’s possible, organizations can realize true innovation in healthcare, embedding information sharing as part of workflow, making it more efficient and accurate, and helping payers and providers rapidly receive the most pertinent information to support more timely, effective, and value-driven patient care.
[i] 2017 CAQH INDEX®, A Report of Healthcare Industry Adoption of Electronic Business Transactions and Cost Savings
Mike Peresie is senior vice president and general manager of the medical network at Change Healthcare. Sajid Khan is senior vice president and general manager of the dental network at Change Healthcare. Adam Sullivan is senior director of artificial intelligence at Change Healthcare.