Tag Archives: referral management

All You Need To Know About Insurance Prior Authorizations In Healthcare

Insurance Pre-authorization in healthcare

Prior authorization is the talk of the healthcare industry since the increase in specializations in healthcare. Any healthcare process has its own pros and cons. Prior authorization is no exception to that. A Health Insurance Company must verify if the patient is eligible for an insurance for a certain drug or procedure. Before the physician prescribes it to the patient, it is a common practice to parallely check for authorization from an insurance company. 

Current Healthcare Insurance Prior Authorization (PA)  Workflow

  1. The physician recommends a lab test – A patient visits a physician complaining of leg pain. The physician suggests the patient get an X-ray to know what is causing the pain.
  2. The lab receives the order – The lab receives the request for the test and initiates the process of prior authorization.
  3. Lab conducts PA – A separate team is dedicated for PA in most of the labs. They check the PA requirements, health plans, etc. They retrieve patient-specific data like the history of medications, diagnosis done, etc
  4. Insurance agents review Prior Authorization – Lastly, the insurance agent reviews and validates the documents sent as a part of the PA process.

The ultimate aim of PA is to optimize patient outcomes by ensuring that they receive the appropriate medication thereby reducing

  • Wastage
  • Errors
  • Unnecessary prescriptions and drug use
  • Cost

Problems presented by the process of Insurance Prior Authorization

1. Time taking process for doctors – Physicians are dissatisfied with the time their staff has to spend interacting with health plans. When a procedure needs authorizing, it consumes a lot of admin time. It includes the time a physician spends persuading an insurance company to cover an expensive medication or a procedure. For most PA, physicians have to follow multiple steps. This involves

  • securing the correct form
  • filling it out with the required information
  • submitting the form to the plan

Physicians say that the overall process takes 30-45 minutes for each PA submission.

2. The cost involved in Prior Authorization – Though PA is the most talked about topic in the healthcare industry, little is known about its cost. In 2009, a study by Health Affairs estimated that on average, prior authorization requests consumed about 20 hours a week per medical practice

  • one hour of the doctor’s time
  • six hours of clerical time
  • 13 hours of nurses’ time

It further revealed that when the time is converted to dollars, practices spent an average of $68,274 per physician per year interacting with health plans. This equates to $23 billion and $31 billion annually! Prior authorization ultimately ends up costing the health care system more than it saves.

3. Patient delay – The real impact of PA is often felt by patients whose treatment is delayed. Nearly all physicians noted that wait times increased the delays in necessary care, which added to the risk of adverse events. According to AMA, a PA decision takes at least one business day for 64% of physicians and 3 or more business days for the rest. During this time, patients are unable to start treatment. These long wait times have a negative impact on patient experience and patient care.

4. Management of Prior Authorization – The management of PA can sometimes be difficult to manage. This is because the requirements can vary widely from one insurer to another. Each one has a different process for submitting prior authorization requests. The process cannot be standardized at times and must be done manually. This will of drain resources and time if this is already limited.

How can the Insurance Prior Authorization process be improved?

Healthcare Insurance Prior Authorization is a necessary step in many practices. But the current process is all too often manual and involves a cumbersome workflow. It may result in delays in treatment and dissatisfaction for patients and medical practitioners. As a result, many are implementing electronic prior authorization solutions to address common issues with the approvals process.

HealthViewX Referral Management solution makes the referral workflow easy for the practices. It has the following features that make the process of Prior Authorization simpler.

  1. EMR/EHR integration – Our System integrates directly with electronic health records (EHRs). This enables healthcare professionals to easily obtain prior authorizations in real time at the point of care. It also eliminates time-consuming paper forms, faxes, and phone calls.
  2. Timeline View – Both the center and the PCP can view the timeline data of the patient in which the referral history is present. Documents and notes can be attached anytime for one another’s reference.
  3. To and fro Communication – At any time of the referral process, the PCP and the center can communicate with the help of the inbuilt secure messaging and voice call applications.
  4. Referral Data Consolidation – It has options for printing the consolidated data about the referrals and the referral history of any patient as a hard copy at any time in pdf/excel.
  5. Secure Data Management – HealthViewX Patient Referral Management is HIPAA compliant. It manages all patient-related documents securely.
  6. Referral Analytics – Helps in tracking the number of referrals and gives complete information about the referrals processed, missed, scheduled etc with the help of a Referral Data-centric Dashboard.

HealthViewX Patient Referral Management solution helps practices in managing their prior authorization process and saves their time and money. Are you a practice looking to ease your prior authorization process? To know about HealthViewX Patient Referral Management System in detail schedule a demo with our team.

HealthViewX Version 2 Is The Solution To The Challenges Faced By The Healthcare Industry

HealthViewX is excited to announce the launch of its all new version. HealthViewX 2.0 is advanced version of our healthcare product that has been,

  • Designed to suit any practice
  • Customized to meet the user requirements

What is HealthViewX?

HealthViewX is a care orchestration platform passionate about building a user-centric healthcare ecosystem. We aim at,

  • Improving patient and provider experience
  • Creating defined workflows
  • Raising the standard of care

We are at the forefront of enabling a collaborative platform for better care coordination & efficiency of care to enhance provider-patient relationship.

How does HealthViewX help?

The HealthViewX end-to-end Care Orchestration Platform guides healthcare organizations through its entire care journey by enabling data-driven decision support and providing real-time insights of patient reported data to promote better care delivery. The platform enables secure communication of patient information and remote monitoring of patient vitals to improve participation and create an interoperable ecosystem for care delivery. We provide three major solutions, they are,

What is exciting about HealthViewX 2.0 ?

In this period, healthcare industry is experiencing its most drastic changes in terms of technology. Every healthcare provider wants to give the best possible care to the patients in their network. So HealthViewX, a care-orchestration technology platform is focused on providing end-to-end healthcare lifecycle management. With enhanced technology, HealthViewX helps healthcare providers in,

  • adapting and evolving to meet the changing needs of the industry
  • providing the best quality care for its patients

Though HealthViewX has the right solutions for the pain points of the healthcare industry, customization was needed for each client. Through many discussions with our clients, we figured out that though many practices have similar challenges, each one had a unique workflow. Everytime we onboarded a new client, we had to modify the workflow to suit their needs. This was time-consuming and difficult. For eg: HealthViewX has a Chronic Care Management solution. One of our clients wanted to track all call logs within different ranges. Another one of our clients wanted to track only call logs with more than 60 minutes duration. This configuration was not easy as the components were static and not reusable.

This is when HealthViewX product experts wanted to make the product more reusable and dynamic. We realized that every practice had unique requirements and workflow. So we enhanced the product by making it a component-based with drag and drop workflow creation in minutes, simple user interface and real time plug & play usable components.

HealthViewX 2.0 features

HealthViewX solution has the following unique features,

  • Report and Analytical Engine – This helps the users in customizing the information they see on their dashboard and also the information they want to download as reports. Customizations mean the users can choose the format and what data or information they want to view. This information will be a great analytical tool for practices who can study such information and make changes accordingly in future to generate more revenue.
  • Module Engine – The users can now create and manage new modules (e.g. CCM, Billing module etc). Previously with version 1, module creation required more effort and time. Version 2 has made module engine so simple that it can be created by the users themselves.
  • UI Studio – The users can define the design and the layout of data on various modules and forms. This customization allows them to view the data in the way they want to.
  • Template & Form creation – This helps in creating and managing various forms in the platform (e.g. Prior-authorization form, Patient referral letter). For eg: In a prior authorization form, the user can design it with the information they need instead of using a standard form.
  • Integration Engine – This engine now enables setting up link between other systems (EHR, schedulers). The users can manage information on such systems easily with the help of this integration engine. Also it manages back and forth communication.
  • Communication component – It enables asynchronous Messaging, Fax, SMS, and Email. It enables the users to stay in touch always so that they don’t miss out on sensitive information.
  • Custom Workflows – The users can now create and update custom workflows that suit their practice.

HealthViewX solution is customizable and user-friendly. The above features are promising and solves most of the challenges in the healthcare industry. To know more about our solution, schedule a demo with us.

How Can A Referral Management Software Compliment An EHR/EMR To Achieve A Highly Performing Referral Network?

Managing patient referrals is a laborious process for large enterprise hospitals. These large multi-specialty set-ups are joint ventures or mergers or acquisitions. The bigger the network, the more complex is their referral process. So these hospitals are relying on computers and customized software to make sure their productivity and patients’ well-being.

In the field of medicine, we need computerization to manage the enormous volume of data that these large enterprise hospitals create and store for each patient. EHR software saves practices time and money, as well as helps them communicate instantly with insurers, hospitals, and referring physicians. Using referral management software with EHR/EMR enables communication between different care providers on patient demographics, diagnostic reports, test results and any sensitive information.

Electronic Health Records

Electronic Health Records (EHR) are digitized forms of patient’s chart data. EHRs are real-time, patient-centered records that make information available instantly and securely to authorized users. An EHR has the patient’s clinical data including demographics, progress notes, problems, medications, vital signs, past medical history, immunizations, laboratory data and radiology reports over time.

Pros of EHR

  • Financial Incentives – Medical providers who convert patient records into electronic ones get financial incentives from CMS.
  • Speedy process – With an EHR system, doctors can immediately place orders for imaging or laboratory work. This reduces errors because a doctor’s handwriting is difficult to decipher.
  • Unlimited access to medical records – With the help of a patient portal connected to the EHR system, both patient and provider can get access to medical records very easily.

Impacts of EHR on the existing referral workflow

  • Easy management of patient data – As mentioned earlier, Electronic Health Records (EHR) are digitized forms of patient’s chart data. It helps is managing all patient-related information like medications, vitals, diagnostic reports, medical history, etc.
  • e-messaging between providers – In order to attest referral information, telephone tag between providers is common. It is a time-consuming process. With EHR software, physicians can e-message across practices. One situation that benefits in particular from e-messaging is referrals. Rather than playing telephone tag to get an appointment scheduled, the physician electronically sends a message to schedule the appointment.

Why is a Referral Management Software is needed in addition to an EHR/EMR?

Large Enterprise hospitals have implemented an EHR/EMR system because it helps them manage their patient data securely. Providers face difficulties in managing paper-based patient records. So EHR implementation is indeed a boon to them. Yes, indeed EHR/EMRs are doing a great job but are they doing enough for patient referral management? What are the challenges enterprise hospitals face in their referral management even after implementing an EHR/EMR software?

  1. Insurance pre-authorization – The process of waiting for the insurance company to respond and approve the procedures or medication is time-consuming. If this process is automated it would save time and efforts of providers, insurance companies, and patients.
  2. Communication between EHR/EMRs – EHRs can communicate only with EHRs within the same network. Sending patient and referral information to providers who do not use the same EHR is complicated.
  3. Patient Referral Leakage – When a PCP refers the patient out-of-network, it leads to referral leakage. PCP can avoid patient referral leakage if the patient is referred to within the network. When that is difficult, patient referral leakage is inevitable. If the patient is referred out-of-network and is not happy with the care given, the chances of the patient coming back to the PCP is less. Referral leakage causes revenue loss and patient dissatisfaction.
  4. Referral Analytics –  As a large number of referrals flow in and out of the network, it is difficult to track the exact number. It is also tedious to track the number of referrals in various status and to close referral loops.
  5. Referral updates and referral loop closure – When PCP refers patients out-of-network, the chances of getting referral updates are minimal. The specialist is usually busy and does not update the referring provider about the referral. Referral updates are crucial in closing referral loops.

How can a Patient Referral Management Referral Management work in cohesion with an EMR/EHR system?

How great it would be if a Patient Referral Management software could integrate seamlessly with an EMR/EHR system? It can help in ensuring end-to-end Patient Referral Management without disturbing the existing system.

HealthViewX Patient Referral Management solution provides easy steps to integrate with a practice’s EMR/EHR system. The patient demographics, diagnostic reports, test results or any sensitive information can be transferred safely. The solution is HIPAA-compliant with complete data security. It has the following features,

  1. Insurance pre-authorization – HealthViewX solution supports automated insurance pre-authorization that reduces the manual work of the referral coordinators. It will save a lot of time for the hospitals.
  2. Intelligent Provider Match – The solution supports an “Intelligent Provider Match” Feature that helps in finding the right specialist/imaging center easily. With this feature, it is easy to find a receiving provider within the network. It will reduce the patient referral leakage.
  3. Referral Timeline – In HealthViewX Referral Management System, any referral has a timeline, to capture and notify the progress of the referral to all the stakeholders. A referral will be mapped to a status which helps in tracking it better. For e.g. – If a patient does not show up for the appointment, the status of the referral can be changed to no-show and a reason can also be given. With the help of a referral timeline, the referring provider can track referrals, share information and seamlessly communicate with the receiving provider.
  4. Improved communication – HealthViewX Referral Management Solution supports messaging and calling features for the referring and the receiving providers to stay connected.
  5. Data Management – The solution is HIPAA compliant and enables secure data exchange of all patient-related documents.
  6. Seamless Integration – The solution can seamlessly integrate with any EMR/EHR/RIS or Third Party application thus providing minimal disruption in the existing referral flow.
  7. Referral Data Analytics – Referral data-centric dashboard gives complete data about the number of referrals flowing out, the number of referrals in various status, patient follow-ups, etc.

HealthViewX Referral Management solution helps in building a secure referral network in no time. We can seamlessly integrate with the existing EHR/EMR system and add value to the system by solving major challenges. Our expert team will guide you in changing to a Patient Referral Management Software with minimal effort. Schedule a demo with us to know more about our solution.

 

Reference

https://vittana.org/12-advantages-and-disadvantages-of-electronic-health-records

 

Why Patients Require Improved Referral Management From Their Doctors?

Why are patients not happy with the existing referral management?

In the existing referral management workflow, patients face many challenges,

  • Location of the receiving provider’s hospital – The patient will prefer visiting his PCP as the PCP will be in his locality. In order to visit a provider in a hospital which is not is the same locality requires a lot of effort from the patient’s side.
  • Patient unhappy with the receiving provider – Many times, the patient may not be happy with the care he receives from the receiving provider. Delayed treatment, waiting time, missed appointments are important reasons for the patient being unhappy with the receiving provider.
  • Time-consuming diagnostic procedures – The patient may have to repeat all the diagnostic tests taken earlier in the new hospital. This is time-consuming and costly for the patient. The referral does not help the patient with an earlier treatment but only delays it.
  • Patient as a communication channel – The patient is made to communicate between the referring and the receiving providers. It may be required for missing patient information, diagnostic test results, patient medical history, allergies, etc.
  • Patient insurance coverage – The process of pre-authorization is done by the referring provider. If not done properly, the patient may have to pay for the treatment in spite of having an insurance.

What challenges do providers face in the existing patient referral management workflow?

  • Limited provider information – Physicians do not have information about the providers within their network. This is to blame for unnecessary out of network referrals. Providers who refer out of network could avoid at least one-third of these if they had access to more robust information about providers in their networks. Even when physicians have access to their health system’s provider directories, they are not using the directories because they don’t have the level of information that is needed.
  • Patients moving out of the network – When physician refer their patients out of their network, patients leave their network. In general, providers referring patients out of their network are less likely to have access to availability, location, network affiliation and insurance information. This is not the best options for a patient. Further, lack of information within a delivery system can result in missed opportunities to connect a patient with a provider with similar expertise who could see the patient sooner, which improves patient satisfaction and retention, as well as care coordination.
  • Inadequate referral information – Even when physicians refer their patients out-of-network, the chances of a successful referral are less. This is because many providers who receive referrals rate the referral information poor. Without referral information, receiving providers cannot treat their patients effectively.
  • Inefficient patient appointment scheduling – For providers who schedule an appointment for the patient, they prefer doing it through phone to shared electronic health records system. When heavy use of the phone occurs, it is difficult for providers to see capacity in their network to book the next available appointment. So they bypass the network and book the appointment before the patient leaves the office.

HealthViewX Patient Referral Management Solution at your aid

1. End-to-End referral lifecycle management with bidirectional EMR/EHR Integration HealthViewX platform supports dynamic forms, workflows, task lists, reports, data visualization and has great integration capabilities. It can automatically pull referral orders from EMR/EHR in real-time. It also helps in configuring all other referral coordinator workflows and tasks with maximum automation. Thus our platform can achieve an efficient end-to-end referral management system.

2. Payer-specific prior authorization process automation – HealthViewX platform has a payer management module that maintains and manages

  • different payer details
  • their modes of prior authorization
  • direct authorization procedures
  • payer forms
  • online portal links

With this information already present, it provides the referral coordinator the capability to automate

  • prior authorization submission
  • status checks coupled
  • fax integration

3. Automated Specialist / Patient Notification & Reminders with Customizable templates and configurable channels of communication

HealthViewX – Template engine platform along with the communication engine gives the flexibility to the referral coordinators to

  • choose the relevant format and mode of delivery for Specialist / Patient communication
  • tie it along with the referral workflows by setting trigger rules and reminder rules.

4. Secure Online referral portal for Specialists with easy touch points via Fax /SMS/Email

HealthViewX clearly understands the specialists’ referral preferences by,

  • Multi-channel referral consolidation that brings all the referrals from every possible source into a single queue.
  • Detailed referral information through which that the Specialist receives all the necessary referral details.
  • Ability to communicate back and forth (electronically or via fax) in a simple and secure way.

These are few notable features of HealthViewX that have enabled referral loop closure from the specialist side.

HealthViewX Patient Referral Management application is the next-generation software for patient referral management. It has provided the best solution to the challenges faced by FQHCs. To know more about HealthViewX solution, schedule a demo with us. Our patient referral management experts will guide you through our HIPAA compliant solution.

How HealthViewX Patient Referral Management Software Helps People In Different Designations In Healthcare?

Why is Patient Referral Management important for hospitals?

Patient begin a journey with the hospital when they are referred to that hospital to improve their health condition. Their expectation of the referral is usually high as they have sought another hospital for better experience and treatment. So hospitals must try to live up to the expectations of their patients. In order to manage huge volume of referrals, a hospital must have an effective Patient Referral Management System in place. This blog highlights challenges faced by operations manager, revenue cycle manager, healthcare IT department, patient referral coordinators and care providers (physicians and specialists) and how HealthViewX Patient Referral Management Software can help.

Challenges faced by physicians and specialists

Physicians and specialists play pivotal roles in the patient referral process. Physicians or PCPs hold the responsibility of initiating referrals. A patient visits the PCP and it is the discretion of the PCP to refer the patient to a specialist. What problems do physicians face in a referral process?

  1. Manual and time-consuming process – The process of creating a referral is too manual and time-consuming. In every stage of the referral, the physician has to put in a lot of effort. Here are few instances,
  • The physician has to wait for the insurance pre-authorization process to be done
  • Finding the right specialist takes a lot of effort from the physician’s side
  • After sending the referral, the physician has to wait for referral updates from the specialist.

From a specialist’s perspective the referral process is cumbersome. A specialist faces the following challenges,

  1. Multiple referral channels – For the specialist/imaging center who receive referrals face more difficulties than the referring provider. The receive referrals through various channels like fax, email, direct message, website, user-filled forms, etc. Managing and tracking all of it manually is a tedious task. The chances of missing out on a referral are high.
  2. Poor communication framework – The existing referral process has no quick mode of communication to contact the PCP or referral coordinator for missing information. The specialist has to wait till he/she gets the necessary information before starting with the referral process.

Challenges faced by referral coordinators

After a referral request is initiated, then it is the job of the referral coordinator to create a referral. A referral faces the following challenges,

  1. Insurance pre-authorization – A referral coordinator has to consult the insurance company if the diagnosis prescribed meet the insurance requirements of the patient. This process takes time as the referral coordinator has to wait for the insurance company to respond.
  2. Finding the right specialist/imaging center – The next big step after insurance pre-authorization is finding the right specialist or imaging center for the patient. The referral coordinator has to consider many factors like the patient’s convenience, specialist’s availability, new specialists in the locality, etc. This is time-consuming as there will be many specialists and imaging centers. Narrowing down the search manually will be difficult for the referral coordinator.
  3. Handling multiple software – A referral coordinator has to handle an EHR, fax system, appointment scheduling software all at the same time. The coordinator has to
    • Collect the patient information and demographics from the EHR
    • Do the insurance pre-authorization
    • Find the specialist
    • Send out the referral as a hard-copy fax

Handling so many things at the same time is tedious for the referral coordinators

Challenges faced by an operations manager

  1. Patient Referral Leakage – An operations manager will be primarily worried about how many patients are referred out of the network. Patient referral leakage is a determining factor in a referral network. In many cases, the patients are referred out-of-network even when there are appropriate specialists within the network.
  2. Referral Analytics –  As a large number of referrals flow in and out of the network, it is difficult to track the exact number. It is also tedious to track the number of referrals in various status and to close referral loops. The operations manager also needs to know how many referrals were sent or received, how many were processed, how many are yet to be processed, etc.

Challenges faced by a revenue cycle manager

  1. Patient no-show rates – After receiving the referral, the specialist/imaging center schedules appointments with the patient. In some cases, the patients are not notified clearly about the appointment. When patients do not show up, it is difficult for the specialist/imaging center to track. It results in revenue loss and patient dissatisfaction.
  2. Costly software – As mentioned earlier, a referral process needs an EMR/EHR, appointment scheduling software and a fax integration system. So many softwares for a single process is not efficient.

Challenges faced by an IT strategist

  1. Handling sensitive patient data – Patient data must be handled securely. Considering the current manual process, it is difficult to maintain data security.

How can HealthViewX solution add value to the process?

    1. Insurance pre-authorization process – HealthViewX automates the insurance pre-authorization process. The provider need not coordinate with the insurance company for prior authorization. The HealthViewX solution will do it for them. This reduces the manual effort of the referral coordinators.
    2. Intelligent Provider Match – The HealthViewX “Smart Search” feature makes it easy for the referring provider in finding the right provider. It has smart filters and search options that help in narrowing down the specialist based on the requirements. This saves a lot of time for the referral coordinators.
    3. Timeline View to track referrals – With the help of a referral status, the referring provider can get to know what stage the referral is. A timeline view shows a history of stages through which the referral has progressed. The chances of a referring provider missing out on referral updates are very less.
    4. Referral closure and feedback – The referring provider can close the referral when it gets completed. The receiving provider and the patient can give a feedback on the referral process to the referring provider. Thus the referring provider can make it easy for the other the next time.
    5. Multi-channel referral consolidation – The HealthViewX solution can capture fax, phone, email, online form referrals or any other referrals in a single interface. It makes it easy to monitor and manage all channels of referrals in a single queue.
    6. Patient coordination framework – After finding the receiving provider, the referral coordinator refers the patient. When the receiving provider receives the referral, the provider will get notified of the referral. Even the patient will be notified of the referral. The receiving provider can schedule appointments based on the patient’s comfort. This will cut down patient no-show rates.
    7. Referral Analytics – Helps in tracking the number of referrals and gives complete information about the referrals processed, missed, scheduled etc with the help of a Referral Data-centric Dashboard. It helps the operations manager in taking informed decisions.
    8. HIPAA compliance – The solution is completely HIPAA compliant which enables secure patient data exchange.

HealthViewX Patient Referral Management solution smooths the referral process and solves challenges faced by people in different designations in healthcare. Do you want to know more about HealthViewX HIPAA compliant Patient Referral Management solution? Schedule a demo with us.