Consumerism fuels fire for real-time claims adjudication - Health plan demonstration models aim to makeit easier for providers to obtain real-time information and simplify the collection process - Man
The industry is meeting these challenges in different ways. One of the largest programs for integrating real-time transactions
is being conducted by Humana Inc., Blue Cross and Blue Shield of Florida and athenahealth Inc. Humana has teamed with Availity
LLC, which serves as a real-time transactions gateway for electronic data interchange.
Humana launched an integrated real-time claims adjudication initiative earlier this year with the goal of making it easier
for provider offices to get real-time information, simplifying the collection process, and allowing physicians to more accurately
collect patient-owed portions of claims at the time of the office visit. The latest phase of the pilot program will include
physician practices that use athenahealth, with its revenue cycle management solution, and Blue Cross and Blue Shield of Florida,
Humana's partner in Availity.
The model Humana is using in the Florida pilot program is the most likely scenario for implementing real-time transactions
in the industry. It's a model similar to the ones used by the retail and financial industries where data from the point of
sale is directed through banks via credit card companies to debit a consumer's account in real time. However, healthcare can
be a little different.
"In healthcare, it's not good enough to make a connection between disparate systems and share a translated message, you have
to encrypt it," says Gordon Sellers, director, healthcare solutions, SystemWare in Dallas. SystemWare serves as a hub for
integrating and sharing electronic information. "It is a real challenge. The security piece in terms of HIPAA [the Health
Insurance Portability and Accountability Act of 1996] compliance means not divulging needed information to the wrong people.
It's a necessary element to real-time transactions, but it adds a layer of complexity."
Many organizations are looking for solutions that improve the processing of existing legacy systems, says IDC's Young. "IBM
. . . is convinced that enrollment information needs to be gathered better and made available to all applications that need
access to it. It is looking at a business server model to provide that. Everything flows from that information, they say.
If you can't identify a person, you cannot move forward with a healthcare transaction."
Jamie J. gooch is a cleveland-based freelance writer.
Jamie J. Gooch is an Ohio-based freelance writer. His areas of expertise include several professional industries as well as marketing and e-media.
Articles by Jamie J. Gooch
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