As most practice leaders can attest, one of the most challenging revenue cycle burdens is dealing with health plan requests for additional documentation. Despite significant strides being made in automating revenue cycle transactions, such as eligibility verification and claim submission, supporting clinical documentation typically is communicated to health plans via fax or mail, or uploaded to proprietary websites.
In an effort to address these inefficiencies, a coalition of industry stakeholders, including MGMA, is advocating that the federal government move forward with national standards for electronic attachments.
Transmitting clinical data in support of administrative transactions is commonplace in today’s healthcare environment. Often, this data is required specifically to support claim submission and prior authorization requests. Yet even when the claim or prior authorization transaction itself is sent electronically, using national standards adopted by the Centers for Medicare & Medicaid Services (CMS), the supporting clinical documentation must be sent manually. The result is costly and onerous movement of data that can slow payment for medical services and even delay the care patients need.
In the current attachments environment, health plan requests for additional clinical documentation to support a claim submission or prior authorization that are sent to the practice through fax or mail often are lost or sent to an incorrect address. Practices also report that it is sometimes difficult to determine what specific clinical data is being requested by the plan. The response by the practice to these health plan requests requires significant staff time to compile the information, then mail, fax or upload it to a health plan website. Because practices often do not know exactly what the plan requires to adjudicate a claim or approve a prior authorization, they compile and forward more information than necessary (a potential HIPAA privacy concern). These manually produced claim attachments are a significant cause of claim denials, payment delays and write-offs for the practice. Manual prior authorization attachments often require physician intervention, taking providers away from patient care, and can delay patients receiving the medications or treatment they require. More health plans are driving practices to their web portal to submit clinical documentation, yet these portals require practices to manage separate user names and passwords.
There would be clear benefits to practices implementing an automated attachment process. Lost or misaddressed health plan requests for additional documentation would be virtually eliminated. Practices would see significantly reduced costs associated with staff compilation and sending of clinical information in addition to the paper and postage costs related to mailing the documentation. There would be improved predictability of health plan clinical content requirements along with an expected reduction in pended, denied or appealed claims and faster payment. For prior authorizations, standardized electronic transmission of attachments would result in faster approval decisions and reduced time for patients to receive medications and medical services.
How often do plans request attachments, and what do manual attachments cost practices? More than half of respondents to an MGMA survey answered “always” or “often” that payers request attachments for claims or prior authorizations, and more than three-quarters answered “always” or “often” for workers' compensation claims. This increases to nearly 100% for some specialties, such as orthopedics. The CAQH Index, a yearly report of the cost for health plans and providers to conduct administrative transactions manually versus automated, found that the provider cost for a manual claim attachment was $5.25 per attachment in 2016.
The problem appears to be getting worse. A May 16 MGMA Stat poll found that 86% of respondents indicated that prior authorization requirements have grown over the past year. A similar poll conducted in March 2016 found that 82% believed that prior authorization had grown in the preceding year. The 2017 MGMA Regulatory Relief Survey found that 91% considered the lack of a standard for electronic attachments to be burdensome.
Standardizing electronic attachments also may open the door to additional functionality for practices beyond purely administrative transactions. Effective care coordination, transitions of care and care management all rely heavily on the efficient exchange of patient information. Having a universal electronic format would facilitate a far more streamlined approach to this exchange. Further, practices that participate in quality reporting programs or transition to alternative payment models such as patient-centered medical homes and accountable care organizations could potentially benefit from standardized and automated clinical data exchange.
MGMA and other stakeholders have communicated to CMS the importance of adopting attachment standards that:
- can be applied to claims, prior authorization, referrals and potentially other administrative processes directly related to the claims payment process
- are defined and adopted for three types of transactions: query, response and acknowledgment
- support submission of structured and unstructured data
- support both solicited and unsolicited attachments (situations where the health plan requests the documentation and situations where the practice proactively sends the documentation to the health plan in support of a claim, prior authorization or other transaction)
- do not allow data that is already part of the original transaction for which an attachment is being generated to be requested again by the health plan in an attachment
Despite being mandated in the 1996 HIPAA law and remandated in the Patient Protection and Affordable Care Act, CMS has yet to move forward with a definitive set of electronic attachment standards. MGMA and other provider organizations have taken numerous opportunities to outline to CMS the clear return on investment of this standard for practices and other industry stakeholders. Without national standards issued by the government, practice management system and EHR software vendors are reluctant to invest research and development resources into an electronic attachment solution.
The adoption of national standards for electronic attachments would greatly improve and streamline administrative transactions and improve clinical data exchange. Significant practice savings would result from reduction in administrative costs associated with manually producing and forwarding clinical documentation for claims, prior authorizations and other transactions. Further, by simplifying and standardizing the movement of clinical data, electronic attachments would serve to support the nation’s move to alternative healthcare payment models. The Association will continue to advocate strongly to CMS that the agency move forward with a regulation and facilitate increased revenue cycle automation.
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