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Interoperability plays a crucial role in medical billing

Medical Economics JournalMedical Economics March 2024
Volume 101
Issue 3

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

Interoperability is vital to medical billing: ©everythingpossible - stock.adobe.com

Interoperability is vital to medical billing: ©everythingpossible - stock.adobe.com

As physicians continue to practice 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 health care interoperability to the forefront of many organizations. This legislation allowed for strict penalties to be applied 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 (EHI).

EHI is defined as the electronic protected health information in a designated record as defined by Health Insurance Portability and Accountability Act 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 and billing records about individuals and other records used, in whole or in part, by physicians to make decisions about patients.

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 occur seamlessly. 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 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 the Healthcare Information and Management Systems Society, there are four key levels of data interoperability within health care:

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: Includes governance, policy, regulatory or legal considerations.

Across the four 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 health care interoperability

In the simplest 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 burden on physicians, and this should include financial burdens.

The increasing burden 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 continues to impact both patients and medical office staff.

Benefits of ensuring medical billing interoperability

When practice management and claim level data can be combined more easily, they can also be analyzed more easily. True interoperability enables 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) are fed and processed into workflow tools and 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 of and remedies for inaccuracies can help providers more accurately code, bill for services, and avoid potential compliance and legal issues. This presents potential opportunities to 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, health care providers and claim clearinghouses all rely on interoperability at their core.

What lies ahead for medical billing and successful interoperability

As many medical practices continue to implement not only electronic health records and clinical tools, but practice management platforms that assist with billing and compliance, it is critical that each of these systems work together seamlessly and securely.

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

Lisa Taylor is CEO of Encoda, a leader in health care 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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