Due to the changing healthcare laws, many insurance companies are making changes due to cost cutting measures and matters of efficiency. All of these changes seem insane because it not only affects the patient but the office personnel that must adhere to the changes within each insurance company. The changes affect the way a patient must go about getting medical services that require approval or other inquiry methods that may have an impact regarding payment of these services or procedures to a physician or a hospital. This is time consuming, because if insurance company A has decidedly reduced it's call center staff because they are also subject to the healthcare laws and now have to find a way to provide healthcare benefits for employees; then who will answer the calls from medical staff who anxiously attempt to talk to a representative from an insurance company about a required authorization?
Many health insurance companies use a third party administrator to coordinate information from medical offices and insurance companies to assess clinical information in order to approve or deny certain medical procedures. Perhaps a health insurance company can save money this way because they do not have to pay a staff to do this because is cheaper to outsource, and if someone needs pre-certification for a test in the wee hours of the morning, they don't have to worry about walking anyone up in the United States here because the overseas shift can just handle to call. Ok, if the company become patriotic and wants to hire it's own they may hire part-time staffers so they don't have to provide company benefits such as health and retirement.
The problem is that due to economic measures, these health insurance companies are putting medical offices in the situation to answer their own calls. By this I mean, that people who work in medical offices and obtain eligibility, referrals and pre-certifictions will need to be able to access a system without contacting an insurance company representative. There are automated systems in place that provide eligibility and precert inquiry information, but with the changes regarding the new healthcare insurances, new and existing this information may not be able to be obtained by automation or by talking to a representative. The EMR system was designed to create an electronic patient chart that can be accessed and used to create legible HIPAA compliant patient information that can be easily communicated with not only the patient but anyone involved in the patients care. Since referrals and pre-certifications are also part of the patients care, Why can't this request of information for approval be generated from within an EMR system?
How EMR can help?
Lets just say medical office EFG is using "Lo pay is better than No pay" EMR system. The EMR works fine for the office and is able to do what most of the costly EMR's available do. A medical staff worker notices that due to the new healthcare changes, in addition to eligibility checking for the new year she now finds that there are new implementations or other third party companies that must be utilized in order to get eligibility and other precert information. This has become time consuming because of the several different health insurance companies and third party administrators. They all require you to sign-up and have a log in. This becomes tedious and often times despite contacting the insurance company they may still have outdated information despite the fact you contacted them about updating it. In investing 101, they always tell you not to put all of your eggs in one basket. With this approach workers go from basket to basket in obtaining all of the information they need and going nuts by the second and or buzzer with the phone ringing. The EMR system can help by integrating eligibility, referral and pre-certification access.
How can this be done?
For example medical office EFG with the use of "Lo pay is better than No pay" EMR system and is able to use the EMR to obtain requests and approvals for medical services. Within the "Lo pay is better than No pay" EMR, there is an icon for eligibility, referrals and pre-certifications. When you select referrals you can obtain a referral through the patients insurance company- all you have to do is make sure you have the correct insurance company and patient/subscriber identification number or identifier. You then just enter the other information as you normally would to create a referral. You can fax it to the doctor who is requesting it, you can print out the referral as well. The generated referral will then be saved as a PDF in the EMR in the patients chart to be access if needed. For pre-certification, once you have the correct patient insurance information you just type in the CPT code or type of test or study that you are requesting precert for and the "Lo pay is better than No pay" EMR will then either inform the medical office worker through the patients health insurance company that either: "no precert is required", "you can initiate a precert through the insurance company", or it will direct you to a third-party administrator to "initiate or create a percert". Since all of the non-clinical patient information is entered-because you are electronically in the patient's chart and logged in to the EMR, then all you have to do is add the clinical information. The physicians office note and other imaging studies can also be sent to evaluate a procedure necessity. A confirmation or case number is generated and sent to the EMR and you can then use that number to check on the status of the precert request if it is not immediately approved. This will reduce the long amount of time on the phone and the nonsense of online access to many different insurance companies and third part administrators. Peer to peer talks, are no longer a problem. The physician can access the "Lo pay is better than no Pay" EMR and for quick access go to the Authorization Requests Log-this log tells you all of the pre-certifications that have been requested, that are in process, pending, denied or that require peer to peer. If they require peer-to peer just select the confirmation number and it will provide the detailed information for contacting a physician for peer to peer. If a test is denied it will suggest another test (you will have to check for pre-certification, the EMR will not do it automatically and it will not obtain pre-cert automatically) it will however, provide information regarding peer to peer with another physician.
This is a solid investment for EMR. Instead of having the patients charts accessed and scattered from one online software to another, let's keep all the eggs in one basket; by using the EMR for all patient access!