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Payer role

One of the key external partnerships an ACO may have is with the payers. The relationship between the payer and provider has evolved. The relationships are transforming the payment and delivery care processes. The payers may require the ACO to sign participation agreements. It is hard to say if providers and health plans will become collabora- tors on ACOs. However, one thing is very clear: Insurance companies’ new interest in health IT services will have a vital impact on ACOs. Health plans are beginning to purchase software vendors that can make HIEs happen, as Aetna purchased Medicity and United acquired Axolotl. Insurance company staff can have the skills and history to deal with risk management, population management and actuarial risk balancing. For example, network offi cials could scan the clinical data and make personal phone calls to primary-care doctors if they haven’t been seeing patients who have high acute-care utilization. The data is also useful in making sure that discharged patients receive necessary follow-up care, and in helping the executives quantify the results of their efforts in metrics, such as reduced readmission rates. Could one surmise that it is time for a fee schedule or payment methodology that payers, providers and patients could agree on that would pay for better quality of care, managing patient populations and productivity?

Member’s health lifecycle

One of the major challenges a provider may experience is not having the complete picture of a patient’s health due to lack of information. Continuity-of-care information that is shared in a timely manner among the patient-care team and enabling care coordination across multiple providers is thus essential for meeting the requirements and workfl ow of the ACO. An ACO’s success in part may hinge on its ability to share patient data at the point of care and rely on his- torical and longitudinal data for use in managing population health. Families may move from payer to payer or provider to provider in their lifetime. Being able to see a longitudinal view of the patient’s health record and the patient’s claims record could provide ACO-participating clinicians invalu- able information. They could effectively treat the patient’s condition, even if a provider, such as a specialist, is given only a portion of that patient’s overall treatment plan or health record. Likewise, payers may need to access records of recent or past procedures processed through another payer for a newly insured life. Whatever the degree of fi - nancial risk in particular ACO contracts, many of them may require providers to use a population health management (PHM) approach. Hence, it would behoove the ACO to review patients who use healthcare services and those who do not use healthcare services. The prevalence of disease in a patient population may be great because patients may go undiagnosed or may have fallen off the provider’s radar screens. In addition, patients with known conditions may

be at risk of developing complications because of healthcare gaps and/or lack of compliance. To do PHM effectively, ACOs could turn to automation tools that not only extend the functionality of their electronic health records (EHRs) but also reduce the burden of routine care-management work on their clinicians.

To do PHM effectively, ACOs could turn to automation tools that not only extend the functionality of their electronic health records (EHRs) but also reduce the burden of routine care-management work on their clinicians.

Standardization of billing and claims operations/ management Payer interoperability and data sharing within billing and claims operations/management consist of standards. The Accredited Standards Committee X12 (ASC X12) is a standards development organization that develops standards for electronic information exchange. Such standards could be those of HIPAA transactions as indicated below: Between providers and payers: • ASC X12 278 Patient referrals; • ASC X12 837 Claims submission; • ASC X12 276 Claims status/inquiry; • ASC X12 277 Claims status/inquiry response; and

• ASC X12 835 Claims payment. Between health insurers and health purchasers: • ASC X12 834 Membership enrollment; • ASC X12 820 Premium payments; and • ASC X12 837 Coordination of benefi ts.

Each of these transactions facilitates payer interoper- ability and aids in data capture and data sharing. Aside from the ASC X12 standards, another initiative will impact payer interoperability and data capture. This initiative is the ICD-10 implementation. The standard electronic health record (EHR) and health information ex- change, being championed by the federal government and the industry, rely on the use of terminology systems for the collection and storage of data. Classifi cation systems, such as ICD-10, have been built to convert the data in these terminology systems to secondary data for a variety of uses. Furthermore, the ICD-10 initiative could allow for more descriptive and better-categorized ICD-10 codes, which can enable diagnosis classifi cations that more completely repre- sent the severity of medical conditions. Payer functions, such


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