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Interoperability and its crucial role in medical billing


There are several technologies on the market today that are designed to prevent problematic claims from ever being submitted in the first place.

interoperability © Siarhei - 271615376.jpeg

© Siarhei -

As physicians continue to live in an interconnected world, medical practices and hospitals must seamlessly exchange information to provide better health management and ensure safe and quality patient outcomes.

The 21st Century Cures Act raised the importance of healthcare interoperability to the forefront of many organizations. This legislation provided strict penalties to any organization that was not ensuring the exchange of patient data or found to be “information blocking”- which is potentially any practice that may interfere with the use, access and exchange of electronic health information.

Electronic Health Information (EHI) is defined as the electronic protected health information (ePHI) in a designated record as defined by HIPAA regulations, regardless of whether the records are used or maintained by or for a covered entity.The designated record set in a physician’s practice typically includes medical records and billing records about individuals and other records used, in whole or in part by physicians to make decisions about individuals.

Simply put, the Cures Act was designed to address barriers to interoperability while improving patient care.

In ideal conditions, connection and integration across many types of platforms and systems will seamlessly occur. However, in many cases medical billing, payer denials and the ability to connect platforms are initially overlooked in their importance for physicians to get paid correctly, efficiently and accurately the first time. It doesn’t have to be that way.

There are several technologies on the market today that are designed to prevent problematic claims from ever being submitted in the first place and tools on the market that help physicians hold payers accountable so they can ensure they are paid every penny they’ve earned.

Types of effective interoperability
According to HIMMS, there are four key levels of data interoperability within healthcare:

  • Foundational: Establishes interconnectivity requirements for systems and applications to securely communicate data.
  • Structural: Defining format, syntax and organization of data exchanges.
  • Semantic: Providing common or standardized definitions for shared understanding.
  • Organizational: This includes governance, policy, regulatory or legal considerations.

Across the 4 levels above, there is a positive impact that can transform medical practices through improved efficiencies, data-driven decision making, streamlined workflows and improved patient engagement and satisfaction.

Goals of healthcare interoperability
In the most simple terms, interoperability improves the speed of patient care and enables providers to better manage conditions. But, and in some instances just as importantly, interoperability reduces the burdens on our physicians and this should include financial burdens.

The increasing burdens on clinicians and physicians to properly code, document and bill for service is well-known throughout the industry. Delayed care due to prior authorizations or medical necessity requirements continue to impact both patients and medical office staff.

Benefits of ensuring medical billing interoperability

When practice management and claim level data is able to be combined more easily, it can be analyzed more easily. True interoperability makes it possible for organizations to seamlessly study trends, review past performance and, perhaps most importantly, make improvements.

When medical claims data from multiple systems (i.e. practice management and clearinghouse data) is fed and processed into workflow tools centralized billing and analytics platforms, there is the potential to more easily notice and flag billing errors both pre-and post adjudication.

The ability to provide near real-time detection and remedies of inaccuracies can help providers more accurately code, bill for services and avoid potential compliance and legal issues which presents the opportunities to potentially stop billing errors before they happen, ensuring practices get paid correctly and accurately upon the first submission.

Without interoperability, electronic insurance billing would be nearly impossible. Insurance payers, healthcare providers and claim clearinghouses all rely on interoperability at their core.

What lies ahead for medical billing and successful interoperability
As many medical practices are continuing to implement not only electronic health records and clinical tools, but practice management platforms that assist with billing and compliance, it’s critical that each of these systems work together seamlessly and securely.

Without true foundational interoperability, it will be difficult to truly achieve the many benefits of new and innovative technologies. The time is now for physician practices and other healthcare organizations to invest in interoperable solutions, systems and platforms.

Lisa Taylor is the CEO of Encoda, a leader in healthcare claims and denial management, empowering medical business offices and billing companies to cost-effectively collect the most revenue in the shortest time possible.

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