Challenge
With the healthcare space growing increasingly patient-centric, many practices are doing what they can to provide their patients with better experiences and more transparency. Billing remains one of the more complex areas, considering the variance between costs and insurance coverage coupled with complex billing codes and definitions. This can lead to issues for both the patient and the practice as neither wants the patient to receive an unexpectedly large bill.
Great Valley Technologies, LLC, a Practice Alternatives, Inc. daughter company, provides the medical community with a certified EHR, expert billing services and practice management software. The company wanted to further simplify the billing process for customers by delivering improved billing transparency.
The existing Practice Alternatives solution provided a simple yes or no answer as to whether the procedure would be covered by the patient’s insurance. It was backed by a display from which a user could access more information. However, this display often presented limited, difficult-to-decipher messages, which resulted in some confusion as to whether patients’ insurance would cover the entire procedure, how much they had to pay and the reasoning behind it all.
To get a better result, Practice Alternatives then queried a third-party company for the full details, such as copays, deductibles, out-of-pocket maximums, remaining amounts and network information. The queries were returned in an “X12 271” coded message, which is a healthcare eligibility/ benefit protocol and a transaction that provides information about healthcare policy coverage. However, the format of these messages wasn’t easily decipherable—the typical 271 message has over 97 different code types, which need to be translated into something legible for users. Additionally, X12 was not an easy format to work with—it’s essentially a long string of text.
Solution
Practice Alternatives originally addressed this challenge by hand-coding a function that would translate the messages by looking up the codes and providing the description to users. However, it was a daunting task and the solution was not easily maintainable by someone who isn’t familiar with X12. Additionally, it meant keeping current on 90+ tables maintained by various outside entities, which could change at any time and with no notice.
This is when Practice Alternatives discovered that it could improve this conversion process with Progress® DataDirect®, a leading data connectivity solution for enterprises that need to better integrate data across relational, big data and cloud databases. Great Valley Technologies, a long-time Progress Application Partner, developed the Practice Alternatives billing solution, Rexpert, on the Progress OpenEdge® application development platform. After discussing the issue with a Progress account manager, the account manager pointed out that DataDirect could handle X12 messages with its converters for EDI.
“With DataDirect, everything we needed was right there,” explained Anne Disney, Lead Software Engineer, Great Valley Technologies. “It took an enormous weight off our shoulders.”
DataDirect converted the X12 string to JSON, which enabled Practice Alternatives to manipulate and translate the various pieces of data in a more efficient manner. Even more importantly, it provided text descriptions of all the codes in the X12 string. Practice Alternatives could take the translated message and put it into the HTML provided to the user, turning numerical codes into detailed descriptions written in plain English and displayed in a more user-friendly fashion.
“This is potentially a game-changer in allowing practices to collect monies upfront, which our experience shows us would otherwise be uncollectable,” added Luanne Wainwright, CEO, Practice Alternatives.
The integration process only took about one week, and Practice Alternatives has been in the process of rolling it out on a practice-by-practice basis.
Results
While Practice Alternatives is still in the process of iterating on the solution, the value of this new approach is already evident among customers. It gives them the ability to better serve their patients by providing more information about the billing process, which ultimately gives patients more freedom and flexibility in the management of their healthcare.
For example, if a patient had shoulder pain and wanted to get a test done, the solution previously could only offer up a limited yes or no response as to whether it was covered. Now, practices can provide a detailed response. Perhaps the patient isn’t covered right now for a scan, but they will be in two weeks when their coverage starts. Now, the patient has the option to reschedule the test for when they are covered. Or if the shoulder pain is too severe, they can opt to pay out of pocket for the procedure and have it done immediately.
Milburn Medical Imaging is a long-time customer of Great Valley Technologies and user of the OpenEdge-based Rexpert. After trying the new solution, radiology billing expert Janice Camacho said, “This is 100% better.”
In fact, this code conversion is actually helping Practice Alternatives realize an entirely new revenue stream. The company recently made a web service available for outside customers that enables them to translate their difficult-to-read X12 271 messages into an intuitive, attractive results page with complete insurance details.