It’s time to innovate to make administrative data interoperable

The healthcare industry has come a long way in its ability to share clinical information, especially across geographic regions and with point-to-point connections. A report by CHIME and KLAS Research shows that nearly two-thirds of provider organizations that have invested in interoperability are satisfied with their progress and say they “often or almost always” have access to the records they need. The report also indicates that the most useful methods for accessing patient data are public HIEs (39%), national networks (36%) and direct messaging (31%); those using large EHR vendors have shown the highest FHIR adoption rates; and, the top use cases for FHIR APIs are patient-facing tools (31%), clinician-enabling tools (27%), and patient record exchange (24%).

As the industry continues to gain ground in clinical interoperability, it’s time to broaden our vision to include the value of another kind of interoperability: the seamless and direct exchange of administrative data.

Increased administrative process and data costs

Examples of administrative complexity are many and varied, including having to fill out duplicate forms, re-entering existing data into multiple systems, and managing data through fax transmissions or worse — human phone calls. Most often, the administrative complexity is part of the billing and insurance (BIR) processes. These processes attempt to answer questions such as:

  • Is this patient eligible for this service?
  • Can we verify the exact benefits?
  • Does this service require prior authorization?
  • Is this provider accredited?
  • Is this provider part of the correct network?

We spend approximately $42 billion annually on administrative transactions according to the 2021 CAQH Index report. Each manual eligibility and benefits verification transaction costs the industry $16.07, while each manual pre-authorization transaction costs $14.49. These costs include the labor required to complete the transaction, but not the cost of collecting information for the transaction or for tracking.

Considering that payers and providers perform 831 million manual eligibility and benefit transactions and 62 million manual pre-authorizations each year, the total cost of these two types of transactions alone is staggering.

What if there was a way to make all this information available to all stakeholders via a secure and neutral network? The time, effort and resources currently required to manage these transactions could be significantly reduced.

The good news is that technologies like blockchain can help make this kind of interoperability possible, securely, in a timely manner, and much easier than you might think.

Achieve administrative interoperability without data aggregation

A blockchain-enabled healthcare network could enable storage and transfer of data over a peer-to-peer network without having to centralize data in a single storage system or even involve an intermediary. This means that data hosted in a hospital’s or payer’s systems can remain there, so that each entity can retain control of its information systems. They would securely expose the data and allow it to be discovered by users based on the permissions they set.

Once information such as eligibility and benefits is requested, a keychain and master index locates the information, matches it with available data, and then passes it to the requestor. A single neutral network operator could provide certification, cybersecurity and compliance.

Such a network could also reduce IT costs by allowing rich solution providers like revenue cycle management companies, telehealth platforms and other healthcare players to also connect through the same network. This would eliminate the need for payers and providers to build and maintain gateways with multiple systems. Even beyond the cost savings, having fewer system touchpoints should significantly reduce the potential for security breaches.

A better way

Payers and providers spend nearly $496 billion each year on billing and insurance costs. As with clinical interoperability, greater administrative interoperability could help eliminate many of these costs, freeing up much-needed investment resources. Leveraging a secure, blockchain-enabled network should be part of every healthcare system’s strategic plan to improve efficiency and reduce costs for a better healthcare continuum.

Photo: James Brey, Getty Images

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