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Healthcare organizations often fail to acknowledge the role that interoperability, payer denials, and medical billing play in ensuring payment to physicians.

In today’s tech-savvy world, people across the globe are connected unlike ever before. According to the CEO of healthcare claims and denial management company Encoda, Lisa Taylor, with this global connectedness comes an increased need for healthcare interoperability. Physicians and their healthcare organizations need systems in which information can be exchanged in a streamlined fashion to support quality health management and safe patient outcomes. As mentioned by the US Food and Drug Administration (FDA), the 21^st Century Cures Act, created to help advance medical product development by adopting innovations at a faster pace, is an excellent step in the right direction. Addressing the issue of interoperability, this legislation stringently penalizes any healthcare organization that impedes the seamless flow of patient data. A Journal of American Medical Informatics Association article notes that the 21^st Century Cures Act also imposes firm sanctions on those who interfere with using, accessing, and exchanging electronic health information (EHI)—a practice known as “information blocking.” As such, this legislation aims to streamline interoperability while bettering patient care.

Unfortunately, Taylor points out that it is common for healthcare organizations to fail to acknowledge the crucial role that interoperability, payer denials, and medical billing play in ensuring accurate, timely payment to physicians. The Healthcare Information and Management Systems Society (HIMSS) suggests four essential tiers of data interoperability, the first of which is Foundational. At the Foundational level, healthcare organizations inaugurate system and application interoperability exigencies to exchange data safely. At the second level, Structural, organizations define format and syntax while organizing data exchanges. The third level is Semantic, at which organizations support interoperability by agreeing upon standardized definitions that promote mutual understanding. Lastly, the Organizational level is fourth and addresses issues pertaining to governance, policy, and law. Amongst these four levels, healthcare organizations witness positive changes in how they function, from improved efficiency to streamlined workflows. What’s more, patients report increased satisfaction. With all of this comes the bonus of improvements in revenue.

Interoperability Can Ease Burdens

According to Taylor, interoperability is a key component in ameliorating the slow speed of patient care while allowing physicians to handle their patients’ needs more successfully. As a result, physicians find themselves relieved of some clinical, administrative, and financial burdens. Rather than delay patient care due to issues like coding discrepancies or prior authorizations, physicians can focus on tending to their patients, and patients can breathe a sigh of relief knowing that their physicians are keyed in on delivering optimal care. Interoperability also allows physicians and healthcare organizations to analyze claim-level data, trends, and past performance with more proficiency, thereby providing them with a solid knowledge base to improve.

Taylor notes that when medical claims data from various organizations is streamlined into one seamless, centralized billing and analytics platform, physicians and organizations will have an easier time locating billing errors. Furthermore, interoperability allows for near real-time error identification and swift remediation in response, thereby lessening the possibility of a malpractice suit due to lack of compliance or other legal issues. Being able to possibly prevent billing errors from happening in the first place guarantees accurate payment on the initial go-round.

Claims management often consumes significant time for physicians and healthcare organizations. Group purchasing organization (GPO) Premier ran a survey and found that Medicare Advantage, Medicaid, Commercial, and Managed Medicaid experienced denials on nearly 15% of all claims. What’s more, 45% to 60% of the denied claims were overturned. According to Gretchen Heinen, RN, PHN, BSN, founder and CEO of revenue cycle management (RCM) solutions company Authsnap, Inc., many physicians are forced to confront revenue issues due to denied claims, and several US hospitals have ultimately had to close as a result of claims denials. However, Heinen urges physicians to remember that most denials can be overturned with a well-constructed appeal letter.

What Causes Denied Claims

Heinen notes several potential causes for denied claims. For instance, an insurance policy’s umbrella may not cover specific services or treatments, perhaps because they are viewed as experimental or subject to certain policy limitations. Another possible cause could be incomplete or inaccurate information on the submitted claim. Additional potential causes suggested by Heinen include submitting claims that don’t meet medical necessity criteria, enlisting out-of-network physicians for medical care, not adhering to prior authorization requirements, patients with multiple insurance policies not ensuring that they’ve coordinated benefits issues and untimely submitted claims.

According to Heinen, physicians and patients must familiarize themselves with the insurance company’s explanation of why they denied a claim. More often than not, they can use this information to support their case in an appeal. However, Heinen notes that having someone with clinical expertise dealing with the appeal would be extremely helpful, as insurance companies typically do not provide fleshed-out responses in their claim-denial letters.

For those who would like to appeal, Heinen recommends considering a few points to ensure the most successful appeal process. First, she suggests that physicians and patients avoid solely depending on proprietary criteria. Rather, they should employ clinical practice and society guidelines. Second, Heinen urges physicians, patients, and their teams to thoroughly comprehend the appeal process, which is summarized in the contract with the commercial payer. If they deem anything written in the contract to be unjust, they should speak their minds. Heinen notes that every payor’s criteria are available for public view. However, this information is sometimes written in tiny fonts on websites. Therefore, all involved parties must read them closely. Lastly, Heinen suggests that whoever is dealing with the appeal has an in-depth understanding of the ins and outs of prior authorization, making sure to educate themselves on any new policies.

Heinen notes that, ultimately, physicians would be best served to arm themselves with a reliable RCM strategy and tracking plan. Maintaining a healthy revenue stream depends on having a low overturn rate, and if hiring an expert helps achieve this goal, it would be wise to do so.