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Data drives decision-making in healthcare

The rules for processing claims are numerous and complex, and may relate to a particular regulation, state, insurance product and medical condition. Under the Medicare Physician Quality Reporting Initiative (PQRI) pay for performance measure, for example, physicians who report on certain quality measures receive a financial bonus from Medicare. “We wrote a rule that puts these claims on hold until we are sure that the supporting documentation is in place,” Piccone says.

Centralized mapping

athenahealth maintains the rules base and performs analyses to help resolve denials. All denial codes returned from payers are mapped to a proprietary, centrally administered code set. When that code comes back in the future, the mapping documentation contains a description of the issue and the steps a user can take to fix the problem. A team from athenahealth monitors changes in denial patterns. “This centralized mapping allows athenahealth to see a normalized view of denials,” says Jeremy Delinsky, VP of athenaNet Intelligence, “so new trends are readily visible.” An analyst investigates to uncover the root cause, and new rules are added to the system to prevent the denial from occurring in the first place.

athenahealth offers its software in a single instance, multitenant model that allows the company to gain insights across many providers and payers. “We do all the back-end work,” continues Delinsky, “so we can examine defects in claims and make adjustments in the rules for each client.” The goal is to have as high a first-pass resolution rate as possible. “About 15 or 20 percent of claims do not go to the payer as first written,” Delinsky says, “but after we identify a problem and the practice revises the claim, the first-pass resolution increases to 92 to 94 percent.”  

HITECH Act and “meaningful use”

The American Recovery and Reinvestment Act (ARRA) of 2009 provides nearly $20 billion in incentive payments for “meaningful use” of electronic health records (EHRs) under the Health Information Technology for Economic and Clinical Health (HITECH) Act. The incentive payments will apply to providers for whom at least 30 percent of patient encounters are accounted for by Medicare or Medicaid (20 percent in the case of pediatricians). The Centers for Medicare & Medicaid Services (CMS, cms.hhs.gov) in the U.S. Dept. of Health & Human Services expects over a half-million providers to receive incentives that could reach a maximum of about $60,000 over five years.

Congress specified the requirements for “meaningful use” as follows: (1) using certified EHR technology for applications such as e-prescribing, (2) connecting the  EHR technology to provide for the electronic exchange of information to improve the quality of care, and (3) submitting information on clinical quality measures to the Secretary of Health and Human Services. CMS issued a notice of proposed rulemaking for a definition of “meaningful use” on Jan. 13, and the public has until March 15 to comment before the rule is finalized.

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