Back in the days before everyone became nose-down into smartphone and tablet screens, a popular game to pass the time was 20 Questions.
One person would select the name of a famous person (living or dead), and the others would ask yes or no questions to try to guess the person's identity. If they couldn't guess correctly within those 20 questions, the person who chose the name would win.
While that game may seem quaint in today's electronic world, the irony is not lost on health payers receiving claims from providers. Because payers are often put into a similar position. When claims come in, payers are often challenged with determining the exact identity of that member/patient. There can be any number of reasons for a discrepancy, including:
• A simple typo when entering the documentation. For example, Smith can become Smyth or Smythe, or patient ID number 139657 can become 193657.
• The patient doesn't have his/her ID number available so the provider uses the patient's Social Security Number in its place (a bad practice, but it happens).
• The patient doesn't have his/her new ID number available so the provider submits the claim under the patient's old ID.
• The patient marries and takes a spouse's name, but the insurance information isn't updated in time.
• The patient is a child, but the ID information provided is for the child's parent.
• The patient uses different payers for healthcare, dental, vision, etc. and gives the wrong insurance information to the provider.
• The provider changes the information intentionally in an attempt to fool the system in order to increase revenue, an example of fraud, waste or abuse (FWA).
• In government-funded programs, one patient might pass his/her ID card to a relative, neighbor or friend so they can obtain services that would not otherwise be available, which also qualifies as FWA.
Whatever the cause, when the claim comes in the payer is left with two options: play 20 Questions in an attempt to find a match or deny the claim. Often they opt for the latter because they simply don't have the resources to manually look through old data to find a match.
Those are the issues the healthcare industry is currently facing, and they are daunting. Here are some ways they can be resolved.
• Implement a National Patient ID. The idea of a National Patient ID has been around for a while, with Medicare being one of the primary proponents. It makes sense both from a patient safety and business point of view. If a single, National Patient ID was attached to every Electronic Medical Record (EMR) and claim it would greatly reduce the confusion caused by patients using their old insurance cards or forgetting their cards entirely and being asked to provide their Social Security Number. It would also ease the way toward sharing information between providers to achieve a 360 degree view of care. In the case of a member using different insurance companies for health, vision, dental, etc. a National Patient ID would avoid errors caused by using the wrong card for a particular service. If the ID card included a photo of the patient/member it would even help reduce cases of FWA card-sharing. Unfortunately, we still appear to be a long way away from having National Patient IDs. If the Centers for Medicare and Medicaid Services (CMS) can't push it through you know it is an uphill battle.
• Achieve true interoperability in EMRs. Again, a great idea but difficult to execute. The effort of creating interoperability, or even better a single, national EMR, would have a spillover effect on claims since in order to consolidate all of an individual's health records you must first match the records to the individual. A mechanism would have to be built into the system to overcome the types of errors that currently lead to multiple records being created for the same patient within the same EMR. While it would yield many benefits, it doesn't appear the financial incentive is there currently to drive it.
• Expand and automate patient matching in payer systems. This one is actually starting to occur. In the past, legacy payer systems were designed to look for a single match, such as the name or member ID. If that match did not occur, the claim would be sent for adjudication and denied, or more likely rejected and sent back to the submitter. New technologies, however, are being developed that will go beyond those surface matching schemas and automatically dig deeper into the payer's records to search for a match. Take the example of a patient giving an old card to the provider. Normally if the name and member ID didn't match, the claim would be denied. These newer technologies, however, will look through the member's history to see if that name ever matched to the ID number. If so, it will then check whether the member has a new, valid ID, and if so will update the record and process the claim appropriately, without the need for manual intervention. This is possible today, across dozens of different parameters. This capability may become even more powerful in the future if payers begin to share certain records, enabling the technology to search the patient's full insurance history for matches. While payers may be understandably reluctant at first to share their member data with competitors, with the right mechanisms in place and a financial incentive to do so this barrier can be overcome.
Playing 20 Questions at a party or on a road trip may be a fun way to the pass the time. But it's no way to run a healthcare system.
Developing the ability to quickly and accurately match patients to their records and health plans, even when the information submitted isn't ideal, is critical to ensuring better quality care, greater patient safety, and lower costs for all involved.
Darrin Haehle is president and chief information officer of Wonderbox Technologies, an agile, 21st century benefit administration software company focused on building next-generation technology for the specialty payer market. Wonderbox Technologies' Enterprise System is the engine that drives the SKYGEN USA family of distinguished benefit management companies. He can be reached at dphaehle@wonderboxtech.com.
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