Referral Care Coordination, Eligibility Standards, Provider Network & Payment Discovery
Integrating four key functionalities into clinical workflows during COTS EMR deployment: referral care coordination, eligibility standards, provider network, and payment discovery.
Health IT
Large healthcare organizations who are seeking to integrate unique administrative and clinical eligibility into their electronic medical records (EMRs) while maintaining a robust provider network face numerous challenges. Specifically, referral care coordination, documenting eligibility standards, utilizing provider network data, and integrating payment discovery into efficient outpatient referral care coordination (ORCC) and a clinically driven revenue cycle.
What the Work Delivered
- Referral Care Coordination: Prioritizing centralized ORCC processes during COTS EMR deployment enables clinicians to maximize the organization’s native EMR system (i.e., Direct Messaging, HIE) and to centrally receive, review, and triage referral-based care.
- Eligibility Standards: When Eligibility Standards are defined, and your COTS EMR is customized, your organization will be able to efficiently send, receive, and pay (when applicable) claims for authorized eligible health care.
- Provider Network: By managing, understanding, and defining a comprehensive provider network, that includes ‘out of network’ providers, your organization’s ability to use automated claim generation functionalities grows.
- Payment Discovery: Prior to a COTS EMR deployment, a payment authority identification and assignment process should be integrated into your Eligibility Standards. This will enable your organization to reduce billing errors and ensure accurate payment reimbursement.
How We Delivered It
Integrate in Tandem, Not After
Our approach prioritizes integrating these functionalities into the initial implementation so that the workflows created extract meaningful data. This allows for instant identification of challenges. This is opposed to deploying a COTS clinical workflow first, then forcing considerations for these key functionalities on top of the already designed and deployed workflow.
Tailored Organizational Standards
By integrating and implementing in tandem, we can create tailored ‘organizational standards’ for ordering outpatient referral-based care, which will include how to define ‘patient care locations’ and ‘referral care routing’. The tailored standard will guide how all data should be reported and tracked, to identify metrics that align with your organization’s goals, resulting in an automated and user-friendly solution.
Reduced Clinician Burden
Our approach will also reduce the administrative burden that can be placed on clinicians as they attempt to manually uphold the organization’s Eligibility Standards. A part of our deployment will include the development of a payment identification and assignment process, that will conduct Payer Discovery more efficiently.
FHIR-Based Provider Network
Additionally, our team will work to define a comprehensive Provider Network and implement a solution that uses Fast Healthcare Interoperability Resources (FHIR) Application Programming Interfaces (APIs) to the upstream data within the clinical workflow.
The Result
Emerging Tech has been supporting the pre- and post-deployment efforts of one of the largest COTS EMR deployments in the United States history for the past 5 years. Our staff ranges from healthcare professionals to solution advisors, that are familiar with every aspect of this deployment process. Our approach to this reoccurring problem has been developed out of identified best practices and lessons learned while supporting this deployment.
Have a Program that Looks Like This One?
Let’s talk about how we can help.