GET SMART

A bill passed during the 80th Legislative Session aims to simplify the process for physicians to access patients’ insurance coverage information. House Bill 522 by Rep. Beverly Woolley, R-Houston, will explore the use of technology to make this information available by the swipe of a card, a keystroke or a fingerprint.

Patients, physicians and health insurance companies all stand to benefit from the legislation. Patients will have accurate, real-time information about coverage and financial responsibility to help them make informed health care decisions. Physicians will be able to reduce staff time spent on administrative functions related to eligibility verification and have discussions with patients at the point of service about their coverage. This will keep the physician from having to send surprise bills to patients after the visit and will keep patients from receiving them. Health insurance carriers will also reduce administrative time spent explaining policy coverage once clients—both patients and physicians—have a better understanding of the company’s policies.

“Providing for the transfer of health benefit plan information will create a more efficient health care system that I believe will reduce health care’s administrative costs and improve health care delivery with well-informed patients, providers and carriers,” Woolley says.

Like other family medicine practices around Texas, the physicians at North Hills Family Medicine in North Richland Hills and its satellite office in Keller labor to access accurate and up-to-date information on patients’ eligibility and benefits information. One of the physicians there, Justin Bartos, M.D., describes the current system as “labor-intensive and cumbersome.”

“Each plan has a Web site and some are more detailed than others,” Bartos says. “The information is current, but the depth of information isn’t what we need.”

Currently, North Hills Family Medicine must employ at least one half- to full-time employee for each of the eight providers to verify their patients’ insurance information. Though the employees generally try to stay ahead of the physicians by contacting a patient’s insurance carrier before the visit, they often spend more time on the phone or the plan’s Web site hunting eligibility information than the physician spends on the actual patient visit.

Barbara Breneman, patient service coordinator and billing specialist for Bartos, uses a one-page grid of common procedures. She goes down the list of categories, subcategories and sub-subcategories asking the insurance company representative about benefits and diagnostic tests. “You have to be specific,” Breneman says. “Every [line] has to be read out to them.”

The first step to alleviating some of this “time waste and resource waste,” Bartos says, is being able to access a patient’s eligibility information, hospital benefits and pharmaceutical benefits so the physician can tell patients what they’ll be responsible for. “The next step down is knowing if bone density tests are covered, EKGs. That’s the kind of detail we need.”

The insurance companies have the information, but getting it to the doctors is the problem. Health plans are required by statute to provide some information to physicians by phone, not through a Web site as most carriers also do. The biggest challenge for health plans will be updating IT systems and ensuring security of information. Physicians will have a minimal investment, most likely needing only a computer and a high-speed Internet connection or a card reader, according to Jared Wolfe, executive director of the Texas Association of Health Plans.

“The basic information on patients, like benefits and eligibility, is already being provided electronically, so it can be done,” Wolfe says. “The level of complexity will depend on how much information and what technology is utilized.”

Originally known as the “smart card” bill, HB 522 charges the Department of Insurance to create a technical advisory committee and implement a pilot program to test electronic data exchange of health information. When it was introduced, the bill specified the information be hosted on a magnetic strip or smart card, but as the legislation evolved, health care stakeholders expressed concern that confining the initiative to one single product would be restrictive in the long run. Wolfe says not mandating one technology will lead to the legislation’s success.

“When you start putting technology into legislation—the pace the Legislature moves will usually be slower than technology—being prescriptive didn’t seem to make sense,” he says. “The real key is how to make it work versus ‘it has to be this card or it has to be this technology.’”

The technical advisory committee, appointed by the TDI commissioner and comprised of representatives from all sectors of the health care industry, will have the job of identifying a technology to work for everyone. Dianne Longley, TDI’s director of special projects, says they’ve already begun selecting these representatives and hope to begin meeting by August. The three most-discussed technology options so far include smart cards, biometrics such as a fingerprint scan, or a Web-accessible database.

Smart cards essentially have two tasks: authenticate the patient’s identity and access the actual information you want to exchange, says Steve Waldren, M.D., director of AAFP’s Center for Health Information Technology.

“The problem is if the patient loses the card, forgets to bring it or breaks it,” he says. “There’s also a problem with how it’s updated. If we’re storing basic demographic information, it would only change about twice a year, but once expanded to clinical data, there will be more need to update it more frequently.”

Waldren says more health plans are using “dumb cards,” which have all the information to identify a patient plus a URL to a Web site or a magnetic strip to direct the user where the information is stored. “The patient would still have to give you the password, but it would be easy to update and you would still have a way to enter basic information and access eligibility information without access to the card,” he says.

Creating a card-independent Web-accessible database is another option. The health plan creates a URL and gives the address to physicians with a secure provider login ID. When patients come to the office, they give the staff person their enrollee number and password to access their specific health insurance information.

Biometrics, such as fingerprint or retinal scans, aren’t a popular option because of system unreliability and lack of flexibility in data storage, according to Waldren. Fingerprint reading only performs the first task of identifying a patient.

“What we’ll likely see is a combination of a device we have,” Waldren says. “I see that as the way to go.”

Though there have been questions about technology and security, many concerns were addressed during the Legislative Session. “I worked closely with Insurance Commissioner [Mike] Geeslin to address concerns of security and to ensure we utilize relevant and secure technology,” Woolley says. “The Department of Insurance is well versed in protecting health care information, and thus is perfectly equipped to ensure that our health care insurance information will be secure as they implement House Bill 522.”

Longley says one challenge will be to make sure the data provided is accurate. “There’s always going to be a lag such as payment toward deductible. If a patient sees a physician on Monday, then goes to a specialist on Wednesday, the health plan might not show your $200 deductible right away.”

The technical advisory committee will have a few more issues to keep in mind as they advise TDI on issues surrounding electronic data exchange. The Council for Affordable Quality Healthcare has already developed a set of transaction standards and rules for anyone who creates, uses or transmits eligibility data. Through the work of the CORE approach, CAQH sets forth a set of interoperable, HIPAA-compliant rules to streamline health care transactions. TAFP worked with other health organizations to ensure the CORE standards influenced much of the language of HB 522.

CAQH Director of Communications Chris McNamara says 25 entities are already CORE-certified, which means they voluntarily agreed to help create the rules, adopt the rules, signed a pledge and began a testing process within six months. Four types of stakeholders can be certified: large provider groups, clearinghouses, IT vendors and health plans.

“Access to eligibility data will be improved with each group that joins,” he says. “I encourage all who are interested in data exchange to become CORE certified as quickly as possible. The more entities using the rules, the more valuable the rules become.”

The objective of CORE is to commit all parties to agreed operating rules before each chooses an individual method. This saves time and money as pieces of the puzzle are carved out from a whole picture instead of having a one body assemble separately crafted pieces after companies and physicians have invested a great amount of their own money in their own projects. The goal in the Texas Legislature as HB 522 was being crafted was to do the work on the front-end instead of the back-end, tracking what had been already completed on the federal and state levels.

“We were making sure to track the work that had already been done,” Wolfe says. “What we didn’t want was each health plan running into their corner and coming back with their own card.”

Several other groups, such as the Mid-America Coalition on Health Care, are working to make sure involved parties incorporate CORE standards. MACHC Vice President Teresa Titus-Howard, M.S.W., M.H.A., says many health plans already have projects in the works. “Those plans out there in the market are really in the lead,” she says. “These same plans are also willing to comply with national standards.”

While recognizing some groups may have to take on more responsibility than others to ensure the initiative’s success, she says the national standards are integral to limiting resistance from any certain group. “We need to work together, that’s why the pilot is so important,” Titus-Howard says.

Texas’ pilot program, as stipulated in the bill, must be implemented in a Texas county by May 2008 and will be the test run for statewide implementation. Though several counties came up during legislative debate—Harris and Lubbock counties were specifically mentioned in the House and Senate—Longley says any county or combination of counties could be chosen for the program once considerations are taken for whether a small or large county, urban or rural county, or greatly or sparsely populated county will be best for gathering an appropriate sample of patients, providers and health plans.

“The pilot is important to see how well [electronic data exchange] works in the real world, how it is embraced by providers, if it’s user friendly, if it works the way it’s supposed to work and if it’s going to work statewide,” Longley says. “The pilot allows us to do that without spending a massive amount of money.”

The advisory committee must make its recommendations by December 2008 on which technology should be used statewide and by what date, without confining health insurers and physician to one single product or vendor. TAHP’s Wolfe says whatever information we gather from the pilot will be beneficial and he sees this effort as “the springboard to increase electronic availability of information.”

Others warn to exercise caution and take this initiative one step at a time, not expecting huge gains all at once. “Eligibility verification is first, then adding deductibles and co-pays, then real-time claims adjudication,” Titus-Howard says.

There is time built in between the pilot program and statewide implementation for health care stakeholders to adjust to any changes such as adopting the software, and purchasing card readers or other technology interfaces.

Longley says health plans stand to gain a lot and will save money over time. “Providers will see gains, too. Everyone sees this as a win-win situation and it’s just a question of how we get there. Everyone will be slightly inconvenienced for a little while, but everyone’s going to have to learn and make adjustments.”

As for the physicians’ role in choosing a technology, Woolley recommends participation in the technical advisory committee. “I encourage physicians to address any concerns or ideas they might have regarding security or technology in transferring health care information,” she says. “It is crucial that they share their experience as we work toward a program that helps patients, physicians and insurance carriers create a better and more efficient health care system in which providing affordable and accessible health care remains a priority.”

In the end, physicians such as Justin Bartos see the greatest benefit as getting staff member Barbara Breneman’s time back. He will also have a better picture of a patient’s insurance coverage, which will allow him and others at North Hills Family Medicine to improve patient visits and patient satisfaction.