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Web tools you can use.
The first online services marketed to providers dealt with billing functions - specifically the electronic transmission of claims (now a HIPAA requirement for most practices). While new services maintain a strong connection to practice management and administrative functions, they are also beginning to directly relate to the physician's sphere, helping you save time and improve patient service.
One new offering that's directly affecting the way physicians work is e-prescribing - the ability to send prescriptions you create with your EMR or hand-held e-prescribing tool (such as a PDA or tablet PC) directly to selected pharmacies. You may also receive electronic refill requests from pharmacies. This is different from faxing scripts from your EMR using fax server technology in that electronic transmission allows two-way communication between pharmacies and physicians.
Leading the way is Surescripts, a company that represents the majority of retail pharmacy chains in the United States.
Here's how it works: First you need to have an EMR or e-prescribing tool that has been certified by Surescripts. Then, when you "write" a script, it is electronically (and securely) sent to the Surescripts network, which directs the script to the appropriate local pharmacy. The patient is then simply directed to pick it up.
This service eliminates most of the hassles associated with handwritten or printed scripts (i.e., illegibility, losing the script), and it provides a more efficient way (secure e-mail versus phone) of communicating with pharmacies for routine but high-volume tasks, such as refill requests. Ordinarily, physicians incur no expense for the service. (Retail pharmacies pay Surescripts because e-prescribing is a more efficient way for them to receive prescriptions.)
Possible drawbacks? Not all retail pharmacies work with Surescripts, and to use the service your software must be certified by the company. (See www.surescripts.com for a list of certified vendors.)
Electronic pharmacy services
A portfolio of tools that allow you to check patients' pharmacy benefit eligibility, drug formularies, and medication histories is offered through a unique organization called RxHub on behalf of the country's major pharmacy benefit managers (PBMs). The basic idea behind RxHub is to offer services at the point of care - that is, as physicians are writing scripts - that help improve formulary compliance. As with Surescripts, these services are offered only through RxHub-certified technology partners - either e-prescribing or EMR companies. (See www.RxHub.net for a list of the company's partners.)
How does it work? Using a certified technology partner's software, a physician makes an eligibility request for pharmacy benefit information on behalf of a patient using RxHub. Assuming that there is a patient match (about half of eligibility requests result in a match), RxHub delivers the information directly to the requester, including the patient's specific formulary plan as well as any benefit limitations or exceptions that the patient's payer may impose. When the physician writes the script, the system tells him whether the drug is on that payer's formulary list; if not, it offers formulary-compliant alternatives.
This service can avoid unpleasant surprises for your patients when they show up at their local pharmacies to fill their scripts. RxHub is also able to provide clinicians with a patient's medication history based on that patient's PBM claim data. This is particularly useful for new or referred patients who have poor or unreliable sources for their medication history. And like Surescripts, RxHub typically offers its services at no charge to providers. (PBMs support RxHub, as they have a strong financial incentive to help physicians prescribe according to drug formularies.)
Online eligibility checking
The ability to check a patient's insurance status can help you determine if he's covered before you provide services (rather than after his claims are denied). Many offices can easily perform this task online using the practice management software they already own. (This capability is commonly located within the scheduler portion of practice software packages.)
To check for coverage, providers can make an eligibility request for either a single patient or a batch of patients (such as the patients scheduled for office visits the following day). An online service, offered through a claims clearinghouse such as Emdeon, searches for the patients within its database. Assuming it finds a match, it will make an electronic request for eligibility status directly to a patient's payer. The payer's reply to the request is sent back to the clearinghouse, which directs it to the person making the request. All of this occurs within seconds.
Remember that the ability to perform such eligibility checking is a function of your practice management software - it either offers this capability or it doesn't (and if it does, the service will most likely cost you an additional fee). The ability to access this service is also payer-dependent. While many payers do make the data available to their clients (at my last informal count, more than 1,000 payers did), it's not universal. And as you might expect, the service is not always able to match your patient with the patients in its database, which means that a request may not yield any meaningful information. Nevertheless, online eligibility checking is much more efficient and reliable than more traditional methods, including calling the payer directly or asking the patient.
This service closes the loop on the electronic claims process, providing an electronic receipt (or remittance) for all electronic claims you submit. It works like this: After your batch of electronic claims has been sent and processed (typically through a claims clearinghouse), participating payers provide an electronic file of the relevant EOBs through the clearinghouse. Those EOBs can then be downloaded directly into your practice management system. Electronic remittance can significantly reduce the time your staff spends posting payments. With this capability, your billing staff will be primarily reviewing rather than entering data.
Like the other online services described in this article, electronic remittance is a function of payers (not all provide it) and your own practice management system (while most new systems offer it, older ones may not). If you are using a clearinghouse, you will want to confirm that it provides the service and ask if a price tag is attached (which is usually the case with electronic remittance).
Bruce Kleaveland is president of Kleaveland Consulting, a management consulting firm focused on healthcare IT. Prior to forming Kleaveland Consulting, he was chief operating officer at a leading EHR company. He can be reached at 206 527 6633, email@example.com, or via firstname.lastname@example.org.
This article originally appeared in the November/December 2006 issue of Physicians Practice.