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The managed care system is "screaming for improving efficiency," and today’s technology is the way to do it, asserts Michael J. Alper, president of Meridian Health Care Management, a managed care consulting firm in Woodland Hills, CA. Meridian provides administrative services to provider organizations and HMOs to support managed care activities.
Technology is available for physicians to verify patient eligibility, schedule appointments, conduct referral transactions, and manage co-payments or other insurance functions on-line, Alper says. "A few years ago, when insurers tried to improve the referral process by allowing faxed documents, the biggest roadblock was that most physician offices didn’t have fax machines," he points out.
The same is true with computer programs that will make the managed care process smoother. Take, for instance, the problem of finding timely and accurate information on a patient’s eligibility, probably the biggest complaint physicians have about administering the managed care business. "We heard a lot of complaints that by the time the hard copy list of eligible patients arrives in the mail, it’s often out of date. Physicians need to move the process to electronic commerce," Alper says.
Many insurers offer web-based products that will verify patient eligibility, but the biggest hurdle is that physician offices don’t have computers and Internet access in the areas where they need them most — the business office, Alper says. "Physicians often have a computer in their office, but they are not widely deployed in the business office," he says.
The one problem with verifying eligibility via the Internet is that patients don’t always remember the name of their insurer and don’t have proof of insurance with them. "There is no universal repository in case the patient doesn’t know his or her insurer," Alper says.
The referral process is typically slow when it’s done by telephone or fax, but if the provider can log onto a web-based product, the system can check eligibility and the appropriateness of the referral on a clinical or administrative basis and give a response in real time, Alper says. "Many insurers are not able to handle referral processing on-line today, but it is absolutely coming soon," Alper says.
Electronic claims processing is much more common, Alper says. The Health Insurance Portability and Accountability Act, which mandates standardization, will make electronic claims submission easier, he adds. Some insurers give providers a bonus if they communicate electronically, Alper says. "It’s because everybody says they need to improve their customer satisfaction," he adds.