Health plans intending to deliver better care and curb provider costs are using a simple clinical messaging tool—care gap alerts—that aims to do both. The alerts, triggered by a patient's office visit and generated electronically, notify providers on the spot if a patient is due and eligible for services. The goal is to "do what we can to deliver better care to our members" and "to reduce the administrative burden on providers," says Joe Miller, director of e-business at AmeriHealth Mercy Family of Companies. "Checking a patient's eligibility for services is an administrative process, not a clinician's role."
Over a year ago, Philadelphia-based AmeriHealth Mercy, the largest family of Medicaid managed care plans in the United States, introduced care gap alerts to its network of providers serving 6.2 million members across 13 states. Despite a few hurdles, the alerts promise not only to alleviate an administrative chore, but also to deliver longer-range health and cost benefits.
Care gap alerts were part of AmeriHealth Mercy's overhaul of its provider portal, engineered by NaviNet, a Web-based healthcare communications network linking more than 800,000 providers in the United States.
The workflow for providers is simple. Before the patient arrives in the office, an administrator logs into NaviNet to check eligibility. Because NaviNet searches multiple payers at once, only a single log-on is needed. Providers receive an alert only if the patient is eligible.
Alerts may be culled from payers' claims, authorization data, pharmacy data, standard Healthcare Effectiveness Data and Information Set data, and in some cases, state guidelines, which may carry incentives. HEDIS guidelines are complied by the non-profit National Committee for Quality Assurance and cover the use of asthma medication, cancer screenings, diabetes care, and the control of hypertension, among other measures.
"There's a good solid group of early adopters. They've jumped on it," says Catherine Weston, vice president, account management, at NaviNet. And that's a good start, given that "meaningful use does involve proving if they've done screenings."