The Connected Physician
A Special Supplement

E-Frontier News

Real-time claims processing is no longer a pipe dream

Real-time claims adjudication—which allows plans to approve claims and tell practices how much they'll pay within seconds of online submission—is spreading. Empire Blue Cross and Blue Shield is rolling out its real-time claims processing system to 70,000 New York physicians.*Anthem Blue Cross and Blue Shield, which has tested a similar system in Indiana, expanded it to Kentucky and Ohio last summer.

Now a new joint venture of Humana and Blue Cross and Blue Shield of Florida subsidiaries is planning to offer real-time claims adjudication to all physicians in Florida next year. The jointly owned company, called Availity, will soon start testing Web-based transactions with doctors in both plans' networks. These physicians' offices will be able to do eligibility and benefit checks, referrals and authorizations, claims status, and claims submission through a single Web site. Doctors who participate with the Florida Blues can already get real-time claims adjudication from that plan, but it won't be part of the Availity service until the pilot is completed. Humana is still considering how to provide real-time processing, says a spokesperson.

After concluding its test phase, Availity aims to sign on as many Florida payers as possible, says CEO Julie Klapstein. Humana and BC/BS together insure 29 percent of the commercial market. The service will be free to doctors.

Pharmacies throw their hats in the e-prescribing ring

In an effort to reduce the number of time-consuming phone calls between pharmacists and doctors' offices, the two leading retail pharmacy associations have launched a new electronic connectivity venture called SureScript Systems. The National Association of Chain Drug Stores (NACDS) and the National Community Pharmacists Association (NCPA), which collectively represent more than 55,000 community pharmacies, say their goal is to "accelerate the adoption of an efficient, secure electronic system to directly connect prescribers and pharmacists."

While SureScript will eventually be used for electronic prescribing, its founders, which include most of the big pharmacy chains, view it initially as a way to help pharmacists refill prescriptions, clarify dosage and other prescription questions, and deal with insurance coverage preferences.

The system, set to launch late this year, seems likely to steal the thunder of RxHub, a St. Paul, MN, company that plans to start an electronic prescription clearinghouse in the first quarter of next year. RxHub, a consortium of three big pharmaceutical benefit managers—AdvancePCS, Express Scripts and Merck-Medco—has been unable to get any of the pharmacy chains aboard so far. The retailers have been reluctant to deal with RxHub, partly because they don't want the PBMs to control communications between pharmacists and physicians.

"These clinical professionals depend on each other, and the communication is important, and they want that to be direct," says Kurt A. Proctor, NACDS' senior vice president of pharmacy policy and operations.

RxHub CEO James A. Bradley insists, however, that the pharmaceutical benefit managers behind RxHub wouldn't intrude on that relationship and that SureScript won't make RxHub irrelevant. Something like RxHub is needed, he adds, to ensure that physicians get information on formularies, benefits, medication histories, and drug interactions at the point of care. Nothing short of that, he says, will eliminate the rework that makes prescribing so inefficient today.

While SureScript doesn't yet have a staff or any customers, it's working with ProxyMed, which already connects doctors with the relatively few pharmacies that accept electronic prescriptions; NDCHealth, the leading electronic data interchange clearinghouse for drug claims; and WebMD, which includes Medical Manager and Envoy, the clearinghouse used by the majority of physicians. As soon as some of the big chains open their information systems to accept online transmissions from doctors' offices—which Proctor says could happen quickly—these vendors and clearinghouses will be able to send and receive data in a standard format specified by the National Council for Prescription Drug Programs, he says.

Offices that use Medical Manager and some other practice management systems already have screens allowing them to exchange data with pharmacies via clearinghouses. SureScript will encourage other software vendors to follow suit, says Proctor. Who will pay for the transactions, however, has yet to be decided.

Big vendors seek to connect providers, Blues in Montana

Another rural state, Montana, may become the next hotbed of connectivity. Several big technology vendors, including Compaq, Hitachi, Oracle and EMC, have formed a consortium that plans to wire the state's entire health care community for electronic transactions. The Community Healthcare Information Consortium, as it's known, was organized by health care IT futurist Mark Anderson.

CHIC already has support from Montana's dominant Blue Cross and Blue Shield plan, which stands to save a bundle by doing business online with physicians. Anderson has also met with representatives of four Montana hospitals and the state's two largest clinics. "We're all eager to learn more about it," says rheumatologist Steve Akre, chairman of the executive committee of one of those groups—the 100-doctor Great Falls Clinic. He notes that Web-based connectivity could help improve care in Montana, where patients and providers are often spread far apart. Greg Hagfors, the clinic's administrator/CEO, points out that the vendors are willing to provide their software and expertise on a risk basis. So they'll get paid only if their experiment yields cost savings.

That approach will be key because of the expense of installing sophisticated practice management systems in the many small Montana practices that don't yet have them. These practices stand to gain additional financial support from the Blue plan. Anderson says that the insurer could save enough by going online with the doctors to subsidize their gear, as well as pay for a new information system for itself.

Satellite high-speed Internet access is latest trick in Axolotl's bag

Besides T-1 lines, cable modems, and digital subscriber lines, you can now use a satellite dish to obtain high-speed, broadband access to the Internet. That's what Axolotl, a Tampa, FL-based company, is deploying to give physicians Web-based clinical and administrative connectivity.

Last year, Axolotl acquired AccentHealth, which has informational kiosks in the waiting rooms of 10,500 doctors' offices. Axolotl has since installed two-way satellite connections to 1,600 of those practices, enabling it to connect with the offices' practice-management systems and Web-based clinical workflow applications. (To connect from your billing software, however, you'll need either Axolotl's Medrium system or a custom interface to another practice management program.) Practices currently using Axolotl's Waiting Room Television Network pay $125 a month for high-speed Internet access, and new customers pay $149 a month, plus a hardware installation fee of $300.

Physicians can also subscribe to Axolotl's Elysium Physician Office Portal, which allows their offices to perform practice management and clinical transactions over the Internet. Assuming users are online with some of their payers, they can submit and track claims, check eligibility, and get referrals online, paying a fee for each transaction

Other facets of the service, including secure online messaging, lab orders and results, and electronic prescribing, are available on a subscription basis. Axolotl's digital dictation/transcription service costs 8 cents a line, 30 to 50 percent less than what transcription services typically charge.

Up to now, Axolotl has concentrated on large hospital systems and their physician networks. Some of these systems already sponsor Axolotl subscriptions for some community doctors, and the company would like to move further into the private-practice sector, says Raymond Scott, president of the company's professional division.

*See "Claims in, approvals out—in seconds," July 9, 2001.

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Ken Terry. E-Frontier News. Medical Economics 2001;24.