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HMIS [Health Management Information Systems]: Linking Payers and Providers

HMIS [Health Management Information Systems]: Linking Payers and Providers. December 2009 Dennis J. Streveler. 2009 UPDATE. Deflation of computer costs continue Emergence of mobile phone technologies Near ubiquity of Internet connections and the emergence of “cloud computing”

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HMIS [Health Management Information Systems]: Linking Payers and Providers

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  1. HMIS [Health Management Information Systems]:Linking Payers and Providers December 2009 Dennis J. Streveler

  2. 2009 UPDATE • Deflation of computer costs continue • Emergence of mobile phone technologies • Near ubiquity of Internet connections and the emergence of “cloud computing” • New “open source” applications for healthcare • Further progress with the Electronic Medical Record and Telemedicine

  3. 2009 CHALLENGES REMAIN • Support and sustainability of computer systems in many environments is still poor • Healthcare systems, especially payer information systems, remain among the world’s most complex systems • Reliability of communications channels is often over estimated

  4. Four Goals of HMIS

  5. Three components required:

  6. SYSTEMS INTEGRATION! • These 3 components must be thought of as ONE effort, since they will closely interlock with each other. • The development of these 3 components must be synchronized with each other – having one advanced component while the others lag will not provide the desired result!

  7. Integration enhances synergy through inter-operability!

  8. What is a claim?

  9. BASIC PROVIDER SYSTEM FUNCTIONALITY • Enrollment, patient registration and eligibility checking • Appointment scheduling • Claims creation and submission • Payment processing • Contract monitoring and negotiation • Business-unit management • Inventory management

  10. ADVANCED PROVIDER SYSTEM FUNCTIONALITY • Electronic Medical Record • “Health Passports” • Clinical Guidelines and Protocols • Telemedicine (telehealth, teleconsultation)

  11. PAYER SYSTEM FUNCTIONALITY • Beneficiary Management: Registration and eligibility • Premium contribution collection • Contracting and contract management • Claims adjudication and management • Fraud detection and provider profiling • Provider payments • Utilization management • Case management • Quality management • Fund management

  12. THE ELECTRONIC LINK BETWEEN PAYER AND PROVIDER • Sharing of patient eligibility and rosters • Transmission of claims to the payer • Transmission back of anomalies and errors • Transmission of payments from the provider to the payer • Transmission of utilization management and quality assurance data from payer to provider (“the report card”)

  13. OPTIONS FOR “THE LINK” • Point-to-point connections • Passive “hub” for switching transactions • A “smart” central clearinghouse which does some edits and audits of information as it is passed through.

  14. CONNECTIVITY OPTIONS OPTION 1: Inefficient point-to-point communications OPTION 2: A “star network” clearinghouse

  15. Project Guidance

  16. Project Guidance

  17. Cost Guidance

  18. IN CONCLUSION • Three synchronized HMIS activities must occur to optimize the electronic flow of information to support provider payments: • Providers must have systems • Payer(s) must have systems • The systems must be able to “talk to each other”

  19. IN CONCLUSION • Costs and implementation timeframes can vary widely based on environmental, technical, organizational and political factors. • It has become nearly impossible to implement a modern strategic purchasing protocol (provider payment scheme) without employing modern information systems!

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