Transcript Availity Overview

An EHR isn’t enough: Information Exchange for
Meaningful Use
The Availity Perspective
Paul Adams
Director of Clinical Solutions
© Availity, LLC | All rights reserved.
Availity Health Information Network
Single Web Portal  Consistent Interface
Real-Time Information Between Care Providers & Health Plans
>65,000
Physician Offices
>150
Direct Payers
Availity®
>1,150
Health Information
Network
>1,000
Hospitals
Indirect Payers
Business Solutions
Clinical Solutions
>400
Vendor Partners
- Clearinghouses
- Practice Management
Systems
- Hospital Information
>455,000
>70,000,000
Employers
Members
Systems (HIS)
- Electronic Medical
Record (EMR) Systems
More than 700 million annual transactions
© Availity, LLC | All rights reserved.
2
Availity—National Health Information Network
WA
Network Strength
ME
ND
MT
VT
• 700M+ administrative, financial and
OR
clinical transactions annually
MN
SD
ID
• 50,000+ physician sites
NH
MA
NY
WI
CN
MI
WY
• 1,000+ hospitals
OH
NE
• 400+ vendorNVpartners
IL
MD
IN
WV
• ~1,300 payers (privateUTand public)
CO
CA
KS
NJ
PA
IA
MO
RI
DE
VA
KY
CA
NC
TN
OK
AZ
SC
AR
NM
MS
AL
GA
Public/Private Collaboration
TX
LA
• AHCA (FL Medicaid)
FL
• HIE Demonstration Project
• Virginia Healthcare Exchange
Network (VHEN) Portal
• AHIP Multi-payer Portal, Ohio
AK
HI
• Oregon Medicaid
• Florida Portal to CMS
© Availity, LLC | All rights reserved.
3
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)
© Availity, LLC | All rights reserved.
4
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 “decisionquality” information.
4. Access must be quick and easy to be most useful.
© Availity, LLC | All rights reserved.
5
Clinical & Business Information
Two Sides of the Same Coin
• 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.
© Availity, LLC | All rights reserved.
6
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
© Availity, LLC | All rights reserved.
7
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.
Jill uses the office
practice management system,
which is integrated with Availity,
to find a date/time for Mr. Davis
to come in.
He will see the doctor in three days,
on Thursday at 2 p.m.
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.
© Availity, LLC | All rights reserved.
She then runs a
CareCost Estimator
to determine Mr.
Davis’ expected
financial responsibility
for the visit.
The amount comes to
$195.00.
8
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.
Mr. Davis is directed to an exam
room where he sees his physician,
Dr. Lewis.
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.
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.
© Availity, LLC | All rights reserved.
9
Mr. Davis leaves the exam
room and stops at the checkout desk. He is advised that
he will be billed separately for
the lab services he received.
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.
Mr. Davis has enough in his
HSA to cover the cost and
presents his HSA card to
the clerk.
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.
© Availity, LLC | All rights reserved.
10
Improving Outcomes and Reducing Costs
Administrative
Business tools improve
workflow and enhance the
efficiency of the visit.
Batch/Clearinghouse
Claims
Remittance Advice
Real-time
Eligibility & Benefits
Claim Status
Referrals / Auth’s
Claim Submission
Card Swipe
CareRead®
Financial
Financial tools
reduce costs and
improve payment
recovery.
Patient
Responsibility
Estimator
CareCost EstimatorSM
Payment Solution
CareCollect®
Across the continuum of care, Availity eases your workflow
Clinical
Clinical tools
support more
informed
decisions and
enhance the
health of the
patient.
© Availity, LLC | All rights reserved.
Health Record
CareProfile®
Electronic
Prescribing
CarePrescribe®
11
Contact
P.O. Box 550857
Jacksonville, FL 32255-0857
904.470.4900
P.O. Box 833905
Richardson, TX 75083-3905
972.383.6300
800.AVAILITY
www.availity.com
© Availity, LLC | All rights reserved.
12