We associate HIPAA with privacy and security of health information, but when Congress enacted HIPAA in 1996, it focused equally on Administrative Simplification. Reducing the burden of calling, faxing and mailing eligibility verifications, authorizations, claims, and related transmissions streamlined everyday tasks like billing. A widespread use of electronic data interchange (EDI) would reduce labor costs and improve providers’ revenue cycle outcomes, and providers do submit most claims and eligibility checks electronically these days. But the opportunity is even bigger. As medical and pharmacy benefits management grows to promote value-based care (VBC), we need detailed patient clinical information to promote better outcomes at lower costs.
Digitizing the paper trail:
Last year, working with one of the largest payers in the US, we learned that providers still spend over $5 billion/year sending clinical information to payers for prior authorizations (PAs), chart reviews (for quality reporting, risk adjustment, etc.), and to support claim submissions. That’s 40 million chart pulls, 48 million PA cases, and 56 million reworked claims. And too often, even in 2018, providers send that information by printing data from a patient’s electronic health record (EHR), faxing it to the payer, and awaiting a response by phone call or via snail mail. Earlier this year, Vox published The fax of life, estimating that 75 percent of all medical communication goes by fax. CNBC reported faxing still predominates – confusing young med students.
Many recognize an enormous opportunity to slash administrative costs and improve patient outcomes. In 2017, the AMA found that 86% of surveyed physicians see PA burdens increasing, and 78% indicate PAs result in patients abandoning treatment. As far back as 2009, a Health Affairs study found that nursing staff spent more than 13 hours per physician per week on PAs.
The API approach:
We know there’s a better way. Application Programming Interfaces (APIs) are the new EDI – supporting conveniences from online banking to mobile commerce to ride sharing. Exchanging EHR data with APIs eliminates the need to search, fax and process paper charts. Using REST APIs, providers send clinical documentation for PAs without any additional effort, beyond the physician placing an order in the EHR.
API solutions realize the promise of Administrative Simplification in an era where VBC demands more detailed EHR data. Think of APIs as advanced EDI for VBC. Or, in plain language, fewer hassles for providers, better outcomes for patients, and lower costs for all.