Area Providers Reap Benefits From ABCBS? Online Service

Typos used to make health care providers sick.

If a wrong procedure code or someone’s nickname was entered on a claim, it could take weeks to get the right information on the form, mail it back and forth, and get the insurance company to pay.

That was before electronic claims and Arkansas Blue Cross Blue Shield’s Advanced Health Insurance Network.

AHIN is a Web-based network that allows providers to instantaneously file claims, check patients’ coverage and eligibility and determine the out-of-pocket expense a patient should pay while in the office.

Warren McDonald, northwest regional provider network manager for ABCBS, said errors on claims made by a provider are now usually identified and correctable within 15 minutes. The system points out fields where errors have occurred — name, address or that a male patient should not be treated for pregnancy — and alerts the health care provider.

The provider can then check its files for the information without having to mail a letter and wait for a reply.

Jerry Bradshaw, president of AHIN and executive director of ABCBS’ health information network, said 75.5 percent of ABCBS’ 4.5 million monthly claims come through the AHIN system. That calculates out to about 3.4 million claims per month, or 113,250 claims a day during most months.

McDonald hesitates to speculate how much money the system saves health care providers. The answer, he said, lies in the fact that denied claims are creeping downward. The statewide clinic denial rate for ABCBS and Health Advantage was 17 percent in 2002 and 16.6 percent in 2003, or a 2.4 percent decrease in denied claims. That means in 2003, 83.4 percent of claims were accepted upon their first submission.

Statewide hospital denial rates in 2002 were 23 percent compared with 21.6 percent in 2003, a 6.1 percent decrease.

The numbers do not indicate self-funded accounts such as Wal-Mart Stores Inc. claims, McDonald said, but are a sample that’s representative of about one-third of ABCBS’ claims.

For the remaining rejected claims, he said, many are duplicates or coding issues. McDonald said the AHIN system helps providers identify those issues and make internal adjustments.

Bradshaw said the average clock speed on “clean” claims is 1.2 days from the time they are entered in the system until the time a check is cut. Many providers report checks in-hand within 14 days, but internal ABCBS data said average statewide claims are through the system in 6.7 days.

McDonald said that number is good even though 15 percent of ABCBS’ claims are still made with old-fashioned paper, which is significantly slower.

“[AHIN] allows them to know before they even leave for that day whether these claims are going to be denied or not,” McDonald said. “Believe you me, that is worth a lot to a clinic manager to know that what they sent off — if they sent off $100,000 in claims — that they’re likely to be successful claims.”

How It Works

AHIN is a Web-based application that allows providers protected access on Blue Cross computers, McDonald said.

Any health care provider in the state who accepts Blue Cross can sign up for the service, which is free. The provider simply applies online, then an ABCBS representative contacts it about specifics.

McDonald said the biggest obstacle in getting providers to sign up for AHIN is lack of Internet access. He said many providers operate on internal networks that don’t have an out-bound connection.

Once logged in, a provider has options to view and register patients and view insurance claims, eligibility functions and other database-driven information about patients in the ABCBS network.

AHIN grew out of a need to link all seven regional offices of ABCBS. “It’s a system that does not require [health care providers] to replace their internal systems; basically it’s an integration effort,” Bradshaw said.

Bradshaw said the company developed AHIN for two years, starting in 1996, then rolled out a beta version. In 2000, he said, the network was opened up statewide. “Of course since that time, we’ve been steadily modifying and enhancing it,” he said.

He said ABCBS made a multimillion investment in the network and spends “a little over $1 million a year to operate, enhance and maintain it.”

HIPAA, HIPAA, Hooray

The Health Insurance Portability and Accountability Act of 1996 couldn’t have passed at a better time for AHIN.

“HIPAA came into being back when we were doing the original development on this,” Bradshaw said. “We really built this system to be a HIPAA-compliant system.”

According to a document published by the District of Columbia Health Department, “This law ensures continuity of health care coverage for individuals changing jobs; includes a provision that impacts on the management of health information; seeks to simplify the administration of health insurance; and aims to combat waste, fraud, and abuse in health insurance and health care.” HIPAA regulations became mandatory on April 14, 2003 (see story, Page 20).

Basically, the HIPAA regs protect patient privacy and cause provider gridlock.

Bradshaw said all claims going into or out of ABCBS are converted to HIPAA-compliant status automatically.

“That has saved this organization literally millions and millions of dollars because we already had this on hand and didn’t have to build something specifically for HIPAA.”

AHIN is a separate LLC but is 62 percent owned by ABCBS. This allows the company to operate as a clearinghouse to make claims HIPAA-compliant before providers send them to other insurance companies.

Bradshaw said AHIN charges nothing to ABCBS to convert claims and charges only 10 cents a claim as a clearinghouse to other firms. He said the going rate through other clearinghouses is about 35 cents a claim.

The Acid Testimonials

Medical Services of Northwest Arkansas operates nine clinics, including the Northwest Arkansas Pediatric Clinic and FirstCare Family Doctor Clinics. Claim information is captured at each clinic, but the actual claim process is centralized at the business office.

“I think AHIN has been a good thing for our practice and I think for our patients as well,” said Larry Shackelford, CEO of Medical Services..

He said the system gives his company real-time data and allows it to accurately collect out-of-pocket money from its clients at the time services are rendered and cut back on refunds as well as billing for uncollected co-pays.

Shackelford said it’s impossible to put a dollar figure to the benefits his company experiences with AHIN. The system, he said, has helped improve the overall efficiency of Medical Services.

McDonald said Mercy Health Systems Clinics of Northwest Arkansas is the single largest claim filer with ABCBS’ northwest region.

Donna Price, insurance billing supervisor of Mercy Medical Clinics, said her four-person group files about 31,000 claims a month, or 1,000 a day on average, with a majority of those going through the AHIN system. She has been using the system since it became available in 2000.

“It’s fantastic,” she said. “Without it, we would be lost.”

Price said a denied claim could take up to a month to correct through the regular mail, but the AHIN system allows her to correct an issue in as little as five minutes.

She said her company’s computers collect data at the end of the day, then send them to AHIN. When she and her staff arrive in the morning, there is a list of denied claims in an “in box.”

The system points out exactly what’s awry with each claim. Her staff researches the defunct claims, sometimes through the AHIN database; makes corrections; and resubmits the file.

Price said the average pay time from ABCBS for Mercy’s 14 clinics is about 14 days.

“It saves us all money,” said Bradshaw. He said it saves the provider from having to make a phone call and the staff at ABCBS from having to answer that call — often many calls for each claim. “It’s one of those unique situations where everybody wins.”