Real-Time Claim Adjudication a "new" way to look at collecting your money

In a time where we are reminded daily that much of the current technologies (EHR, HIE, EDI, and others) will reduce medical error, improve patient care, we tend to overlook the prolific results that other technologies have to offer to health organizations. The market offers that great solutions that billing departments across the nation would appreciate how it can reduce claim denials, put money in the bank much quicker and overall improve the practices bottom line.

Real-time claim adjudication (RTCA) is a solution that enable medical organizations to bill for services before the patient leaves the practice. This allows for the organization to submit a claim with the procedures performed and get a response displaying the allowable charges and patients remainder responsibility based on the contractual agreement.


This has been around for some payers in some states. Humana, some Blue Cross Blue Shied of some states (BCBS of NC has started the development but has not officially released any target dates). Some PMS vendors have been able to successfully enable practices to take advantage of this functionality. AthenaHealth was one of those vendors, with their RTA (Real time Adjudication) services, it makes for a very attractive model for any practice looking to lower the denial rate on their claims.


Using Real Time adjudication is a no brainer when one begins to realize how much time is spent on claim filing, refiling and working the denials. It is known that insurance eligibility verification does resolve some of the claim denial issues, however, much of the billing departments pains lies in dealing with payers who may deny some procedures and not others within the same claim, and then the battle to explain to the patient why they are now responsible for the balance.

According to some recent MGMA statistics published in http://www.mgma.com/SwipeITWaste/ we can see some of the costs associated with claim denials:

57,168,299 Number of claims per year that must be resubmitted due to payer denial due to incorrect patient demographics from non-electronic registration


857,524,484 Minutes per year to resubmit claims denied due to payer denial due to incorrect patient demographics from non-electronic registration


14,292,075 Hours per year to resubmit claims denied due to payer denial due to incorrect patient demographics from non‐electronic registration

289,762,993 Dollars saved per year by not having to resubmit claims denied due to payer denial due to incorrect patient demographics from non-electronic registration


While in the perfect world RTCA would work so well with an EHR, especially when the provider can submit the encounter electronically right after the visit, it is important to note that even if a physician write the data or circles the procedures and diagnosis on the paper charge sheet, the checkout individual may have the ability (depending on the Practice Management System) to perform the RTCA task and benefit from this wonderful technology.

High level review of new proposed certification process

With the recent publication of the Proposed Establishement of Certification Progreams for Health Information Technology, it has been the most anticipated item since the meaningful use proposed requirements. As many have anticipated, CCHIT is in fact on top of the list of the most likely to become the certification body or the (ONC-ACB) ONC Authorized Certification Body.

While most or possibly all the proposed rule focuses on what are the requirements on the certification body, testing and accreditation. The HIT recemendations very much in line with the CCHIT and that also includes the costs of the actual certification which still range from 30,000 to 50,000 dollars for complete EHR/EMR or 5,000 to 30,000 dollars for modules.

The document outlines some estimates on what products will be tested, including statistics on Commercial/Open Source EHR products, Commercial/Open Source EHR Modules and Self-Developed Complete EHRs modules. The total count of products tested is about 181.

The document also outlines that there will be addiotional certifications that the ONC will potentially use for other technologies. The reference was made to the Personal Health Records (PHR) as well as Health Information Exchange (HIE).

The much anticipated Proposal for certification or Certified EHR

While many are still talking to the EHR vendors at the exhibit halls at the HIMSS 2010, The Office of the National Coordinator for Health IT (ONC) released yesterday the notice of proposed rulemaking (NPRM) for the two certification programs. This proposed program has two proposals in it. One that will be temporary and the other would be permanent.

The proposed program outlines the following:

The first proposal would create a temporary certification program that would be issue temporary certifications through the authorized testing and certification bodies (ONC-ATCB) to test and certify complete EHRs/or EHR Modules. During this first proposal the ONC would assume most of the responsibilities during the temporary certification program. This means that no other organization (private ones) would serve as an accreditation body.

The second proposal would create a permanent certification program that would replace the first temporary proposal. This would also mean that the ONC is intended in allowing approved private sector accreditor to fulfill the responsibility of the accreditation body.

The National Institute of Standards and Technology has been working with the ONC to develop the test method and infrastructure that will be used by many of the testing laboratories in the testing stage for both proposed certification programs. This entity (NVLAP) would include specific calibration and or test standards related methods and protocols that would satisfy the needs and requirements of an “Certified EHR”.

The details of what would be the methodology used in the certification test is defined as “The same basic methodology used in third-party conformance assessment”.

More details to come once I can get through the 184 pages of the proposal.

News Media Party at the Georgia Aquarium HIMSS 2010

Another highlight of my day was the exciting news Media meet up. Organized by John Lynn creator of the EMRAndHIPAA.com (Great healthcare informatics resources). During this meeting, I was fortunate to meet up and discuss with several individuals the current challenges our healthcare faces as well as some of the exciting changes going on. John and I got do talk about healthcare technology, ARRA and some of the challenges we all face in this field. John who is very passionate about the healthcare field shared with me some of his thoughts on the current ARRA and impact it has on healthcare practices.
Jean DerCurahian who is a news writer for TechTarget was also attending, and had the opportunity to exchange some thoughts. We in the healthcare bloggerspere have a lot in common. Sharing our thoughts, opinions and experiences hopefully can bring value to others.

Visiting the exhibitors at the HIMSS 2010

The second half of my day I did have the opportunity to walk through the exhibit halls. And while it is overwhelming at first, I had my list already prepared of vendors I wanted to meet up and discuss their products. I categorized the vendors I wanted to visit into the following sections. This is just a tiny list of the ones I visited, but this was my initial list I created before hitting the exhibit hall:

EHR vendors
GE, AllScripts, Greenway, NextGen, e-MDs, eClinicalWorks,DDS Inc. (OpenVista)

Technology and Hardware vendors
DELL, IBM, CDW, Microsoft, Fujitsu, JAOTech

Solutions, Service providers
MEDNET, Claim processing with CPeople, Online Backups, MeDecision

Standards and HIE
Hl7, NHIN, NCHICA

Vendors with the coolest toys for my 3 year old.

Too cool to miss:
Microsoft Surface, NHIN (participating vendors and the IHE)

My first day at the HIMSS 2010

So, the HIMSS 2010 is still going on, but I definitely needed to take this opportunity to collect all my thoughts and review my notes to see what I have learned so far.

My first day went as follows:

It started out with a great presentation done by the Governor of Vermont Jim Douglas. He discussed several of the advantages of having electronic health data and also how it will help the states improve healthcare and reduce the costs. He recognized that most governor are dealing with difficulties balancing their budgets while trying to avoid making any major cuts to critical services. He also covered that a big chunk of his state’s budgets is taken by Medicaid (26% to be excact) and that with the help of healthcare information exchange he is encouraged to see that there will be some potential cost reductions.

One very interesting subject that was brought up and cough my attention is what credentialing and jurisdiction will need to be applied when Telehealth becomes widely adopted. As we all know, TelHealth is when providers from out of state are providing care to local patients or providers instate are caring remotely for patients in other areas. This poses the questions on who gets taxed, what credentialling entities will be used and so forth.
While he did not discuss in details his thoughts on what is going on in capitol hill in regards to the “healthcare/insurance reform”, he did point out that it is a far more challenging task for each of the state governors ahead in reguards to dealing with balancing their books and continue to cope with the ever increasing healthcare costs.

Some of the additional sessions I attended included the review of "Meaningful Use" presented by Sanjay Shah and how the ARRA affected their hospital. He discussed how they have started planning on going paperless several years prior to the enactment of the ARRA. He was able to provide some very good insight to what hospitals need to plan for, and how the three stages of Meaningful Use will impact everyone.

In the presentation he did outline how there are still some areas where his hospital is facing some potential Meaningful Use Gaps. This included e-prescription needs, CPOE implementation outside of the ED, and potential upgrade requirements once the certification is announced.

Next came a presentation by Gregory T. Fairnak the Chief Architect of CONNECT Gateway project. And as he started talking about Opensource and some of the technical aspects of the solution, I was in cloud nine. This was one of the highlights of my day. As a junior software architect and a developper, getting to interact with Greg was a delight, and a great opportunity to pick his brain on some of the details of the CONNECT. I also had the opportunity to meet another icon “in the Opensource arena”. As many in the interfacing world already know, Mirth Project has been in the front lines of the EDI and Interfacing . I have personally assisted many of our clients overcome some of the high costs of interfacing by utilizing this powerful FREE solution. I had the chance to have a short conversation with Gary Teichrow one of the creators of Mirth. It was such a delight to hear how the product came about. I expressed by appriciation to his product creating and thanked him for such a great contribution to health informatics.
It is critical to also note that some of the Mirth components are being utilized by the NHIN (National Health Information Network) which as everyone already knows is the backbone of the federal healthcare information exchange for CMS, SSA, DoD and other federal entities.

This concludes one part of my day at the HIMSS!

North Carolina gets its share of the stimulus money and a boost to help with EHR adoption

Today the white house announced what has been awarded to the different states to support Health Information Exchange and assist care providers with training and technical support with Electronic health records.

This makes the state of North Carolina one of the 41 states to get $ 12.9 million dollars in funding to facilitate HIE for the state. While there are several other already established health record exchange initiatives, the NC HWTF (North Carolina Health and Wellness Trust Fund) has greater potential to get a strong NC HIE started.

In addition, with the establishment of the regional extension centers and their awarded 13.6 Million dollars available through North Carolina Area Health Education Centers Program (AHEC) North Carolina care providers will have better access to onsite technical assistance to help with the adoption of electronic health records.

For a full list of grants awarded visit: http://www.whitehouse.gov/the-press-office/sebelius-solis-announce-nearly-1-billion-recovery-act-investment-advancing-use-heal