Background
As laboratories grow in the competing diagnostics services industry it has become
a must that they provide some form of interface to physician offices to get work
from them. These interfaces could be in the form of patient demographic interface
to physician practice management system or an orders
... The lack of a standardized list across
PMS/EMR vendors is a huge problem ...
interfaces from the physician's EMR.
Laboratories have to rely on the patient demographic and insurance information stored
in these PMS/EMR systems. There are several hundreds of these PMS/EMR vendors in
the country and each system allows physicians to store master insurance records
in their individual format. Each master insurance record usually comprises of a
unique insurance code, insurance name, address and a phone number. Most systems
prefer a method of generating these unique insurance codes on-the-fly i.e. at the
time the physician office creates a master insurance record. This creates an environment
where the code for say "Aetna" for the same PMS/EMR could be different in different
physician offices. Laboratories rely on an ordering system (Outreach) or EMR to
send these electronic orders to them. Internally, most laboratories also have an
LIS and optionally a separate billing system. These systems also have their own
master insurances.
Laboratories want to get paid for the services they provide and they generate most
of their revenue by billing insurance companies for their services. The lack of
a standardized list across PMS/EMR vendors is a huge problem, as it forces the laboratories
to maintain a cross-referenced list of insurances between each physician's system
and the laboratory master insurances.
Current Solutions and Limitations
Laboratories manage their internal master listing of insurances typically in excel
files. Every implementation of an electronic orders interface requires laboratories
to perform a cross-reference mapping of insurances. Most laboratories have some
form of mapping implemented and the most common of these are either a one-time cross-reference
mapping during the installation or some form of a software program that performs
the mapping. Both these methods have some serious limitations which eventually lead
to increase in bad-debts or inefficient billing.
In this option, laboratories will get the latest listing of insurances from the
physician office and perform the cross-reference mapping manually. While one-time
mapping works great for the day of the implementation, it does not take into account
that the physician's data is in a constant mode of change. Patients switch insurances
when jobs change and physician offices update their data. New patients visit doctor's
office with some new insurance card and the offices with add a new insurance to
their database. The more the doctor's office updates their insurance master listing,
it decreases the quality of the previously performed mapping; eventually not assisting
the laboratory in their overall goal of "Increased Revenue".
While software application to do the mapping appears to be the easiest route, it
comes with a significant limitation. Physician offices often misspell insurance
names and also use the fields in PMS/EMR to store additional information about their
billing. As an example, an office might just add an asterisk next to the insurance
name to mark that insurance as an HMO. It would be almost daunting for a software
program to determine and resolve such discrepancies. As everything is tied into
the overall revenue of the laboratory, successful laboratories go the route of hiring
personnel and performing the task of mapping it manually. "Increased Revenue".
The ideal solution would be to have an industry standard master listing shared between
all software vendors throughout the healthcare industry. That would be a major undertaking
by any company and would take several years to implement. The most viable best-case
option for laboratories would have been to have some form of a system that captures
and stores insurances from all physicians' offices and allows laboratories to control
the crossreference mapping for all their accounts from a centralized location. ELLKAY
has built this solution in the form of Live Mapping.