4 Ways ADT Event Notifications Improve Payer Performance

As a result of CMS CoPs requirements and shared risk arrangements, admission, discharge, and transfer (ADT) notifications are increasingly playing a more crucial role in coordinating care between providers and payers.

Historically, four areas have posed problems for payers, beginning with the lack of timely information about a member’s admission, discharge, or transfer from a hospital to a sub-acute setting.

1. Lack of Timely Admission, Discharge, Transfer Information

For health plans, admission to an out-of-network provider raises costs in the absence of pre-negotiated rates, which also increases member out-of-pocket costs and negative member satisfaction and retention with the health plan. Future premium increases due to network leakage are also a by-product of higher medical delivery costs. “Payers are at a significant disadvantage by not understanding the treatments their members are getting or, almost more importantly, what treatments they aren’t getting,” says Bevey Miner, Health IT Strategy/CMO of Consensus, a division of J2 Global.

“And that gap in care is so important to meet not only just better health outcomes but also a very long and complicated list of CMS HEDIS quality metrics put in place to encourage health plans to think about its members that are not getting some care that they should be getting.”

By ensuring that payers are receiving these important ADT event notifications, “they can digest, understand and act on with clearer picture and utilization of their members,” Miner adds. “They’re incentivized financially by CMS to meet a percentage of those HEDIS measurements. And they can fall out of favor really badly if they have a low overall Star rating.”

A simple ADT event notification can give payers tremendous foresight to prepare to engage and support their members more proactively.

2. Proactive Care Coordination

Proactive care coordination is likewise a challenge for payers not tied into the ADT ecosystem. Without adequate information about the patient transitioning from one site of care to the next, health plans are handcuffed in a way from engaging the necessary resources prior to discharge. By leveraging ADT event notifications for members, payers can enable their clinical teams to determine a patient’s need for durable medical equipment, long-term care, hospice, skilled nursing, and other community resources, some of which require a prior authorization that can delay the care.

“Hospitals and HIEs have been generating ADT notifications for a long time,” observes Edie Hagens, Senior Business Development Executive, Healthcare at Consensus/J2 Global, “If you’ve ever had the pleasure of looking at an ADT notification in its raw form, it looks a lot like what came off a dot matrix printer. You can find the patient information in there if you really look hard, but it’s not really usable to a clinician who’s trying to make care coordination decisions quickly and easily.”

To tap into the full potential of ADT notifications, payers need technology partners capable of transforming these raw data into usable formats integrated into their case management systems. “Well implemented technology at the point-of-care enables collaborative decision making for providers and health plans to effectively triage care for the best possible outcomes?” Hagens notes.

With health plans subject to Star ratings, which includes metrics for quality and patient experience, all stakeholders are incentivized to do the right thing at the right time for the right level of care.

3. Payer Enablement of Interoperable Real-Time Notification Solutions

Payers have tremendous power to assist providers in advancing healthcare interoperability through the adoption of real-time notification solutions.

“I anticipate that there will be help from the payer community to support more collaborative data sharing within provider EMR workflows versus sending docs out to portals,” Hagens reveals. “I know that’s happening in pockets already, especially when there’s aligned risk and quality goals between payers, large IDNs, and sub-acute stakeholders.” Thinking bigger picture, the exchange of health information between payers and providers will be instrumental to their performance in risk-based care models (accountable care organizations and the like).

“In risk-based models, the payer definitely sits as a stakeholder at the table along with network providers,” Hagens explains. “ACOs often leverage existing community health information exchanges to streamline and reduce connection expenses and provider friction. Payers are stakeholders in many of the HIEs, enabling transparent data sharing through a common community framework. Ideally, in the next generation, we need to leverage these common frameworks to support many sub-acute use cases, device enablement, and home-based care delivery. Far beyond simply finding a patient or member, we need to focus on an interoperability framework that supports clinicians efficiently in their existing EMR workflow and beyond with meaningful data.”

4. Electronic Prior Authorization (ePA)

A recently proposed rule issued by the Centers for Medicare & Medicaid Services (CMS) has at its core significant changes to the process for managing prior authorizations. The federal agency is working increasingly to minimize the use of fax machines for completing time-sensitive tasks and shifting the emphasis to electronic prior authorization transactions that rely on HL7 FHIR and application programming interfaces (APIs).

According to Hagens, the traditional approach to submitting prior authorization requests via a payer-specific portal for each health plan, with each containing different clinical and business rules. Add to the mix unique CMS rules, the whole process clearly puts the stress on the providers to shoulder the burden around prior authorizations.

By leveraging NPLP and artificial intelligence into the process, automation can reduce inefficiencies and delays from occurring.

“Our vision is to apply NLP and AI to identify structured notes in a document such as urgent to determine prioritization,” says Miner.

“We have a number of payer clients that were using paper faxing for prior authorizations, and that’s a lot of paper that needs to be processed by a payer,” she reveals. “What happens in many instances is that the request for prior authorization is going to sit there. That’s not good, considering some PAs can be life-critical, such as a chemo patient who needs to have prior authorization before she can move on to another set of chemo treatments. It can also be very difficult for the patient.”

Efficient and effective health data exchange is essential to the right care being delivered at the right time for the right treatment. With the adoption of an all-in-one real-time event notification solution, payers can work alongside providers to ensure that their members are on a path to better health outcomes that reduces waste and frustration.

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About Consensus Signal

The real-time ADT notification solution used by these health systems is powered by Secure Exchange Solutions (SES), which provides secure, cloud-based clinical data exchange solutions that accelerate interoperability between healthcare communities. Consensus Signal has joined in partnership with SES to offer real-time ADT notifications to hospitals and health systems. To learn more, go to www.consensus.com/signal/