How to build better document exchange infrastructure for care and payment coordination

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How to build better document exchange infrastructure for care and payment coordination

October 06, 2020
John Harrison
By John Harrison

The shift to value-based reimbursement models has increased the communication and collaboration needs of both payers and providers. Providers must communicate the medical necessity of services to government and commercial payers within quick turnaround deadlines. To support provider’s authorization requests, payers often need to review supplemental clinical documentation, commonly referred to as attachments, which include lab results, operative and procedure notes, and discharge summaries. Failure to submit documentation on time can result in care delays for patients as well as denial or reduction in payment to providers.

Though the move to interoperability has been a focus of the healthcare community and their partners, most providers continue to manually send medical attachments to payers and other care facilities, by fax or mail. According to the 2017 CAQH Index, 84 percent of the estimated 204 million claims attachments submitted by providers to health plans that year was sent by mail or fax. Only six percent of attachment submissions were completed using a structured electronic data interchange method that would allow providers to send supplemental patient documentation to payers and automatically associate those attachments with the appropriate record in a payer’s claims, care management, or quality management systems.

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The reality of today’s healthcare document exchange: Fax, PDF, and disparate data structures
Why do providers continue to rely on methods of document exchange like fax machines and legacy fax server software? Fax has been a proven method for exchanging healthcare information for decades. Older fax hardware and communication lines equipment are known to cause challenges for exchanging critical patient documentation in a timely manner. An unreliable system for sending and receiving faxes can result in delays in document delivery, which means that providers may not get paid, and patients may fail to receive the care they need when they need it.

Many informed observers attribute providers’ and payers’ continued reliance on traditional paper-based fax to the healthcare industry’s slower digitization pace compared to others. While there is certainly validity in these arguments, there’s also another aspect: better interoperability options are not accessible to a wide swath of care providers, and fax is a simple, cost-effective, and universally accepted alternative.

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