This Small Business Innovation Research Phase I project will attempt to resolve inefficiencies in the processing of health insurance claims. A total of 8.3-18.1 billion transactions, including eligibility verification, claim submission, etc., are performed annually in healthcare with only 30-50% of them being electronic. These paper-based transactions in claims processing result in system-wide inefficiencies which lead to inaccurate claims assessment, delayed settlements, losses due to fraud, litigation, regulatory non-compliance. The proposed innovation brings to bear a newly-emerging set of health-care IT standards coupled with the ubiquitous cellular mobile platform to provide an integrated solution throughout the payer-consumer-provider healthcare value chain.
This project proposes to mitigate inefficiencies in collaboration with a health insurance company that is a thought leader in claims processing, by integrating innovative mobile technology and applying it in a manner that circumvents any significant reworking or replacement of existing claims processing systems. Health care costs are approximately 16% of GDP, and represent a meaningful drag on our nation?s economy. If this proposed approach is successfully deployed, it promises to address a significant barrier to the efficient delivery of healthcare with the United States.
Mobile Green Mobile Health Card Summary: Intellectual Merits Mobile Green, Inc. (MGI) proposed to integrate existing mobile platform technology with claims processing APIs to allow a text-messaging (SMS) enabled mobile device to serve as a virtual health insurance card. We sought to develop a solution for the problems that are a direct result of the profound inefficiency in US Health Care Payments and Communications Systems. The complexity of US Health Care is particularly reflected in its IT systems, which pre-date the web and mobile technologies, and often are written in fortran or cobol. They are not interoperable in the majority of cases, which harms not only financial returns to health care providers, but also compromises the health outcomes of patients. Briefly, invalid or outdated health insurance information is costly both for the provider and insurance company; Mobile Green’s proposed solution is beneficial for both parties by reducing the number of bad claims processed. The potential savings for the Health Insurer alone would be greater than $2 million a year. Additional savings were also likely to providers. This would be achieved by delivering patient eligibility information directly to the patient’s phone using SMS, in response to an SMS request by the patient. During the Phase I period, we achieved the following results: Integration with BCBS Nebraska’s eligibility systems, which also allows us to check eligibility on any Blue Cross customer from any state. Full integration with a test site on scheduling; partial integration on billing. Conception of a scalable and efficient method to maintain state while using SMS as a trigger for workflows executed; validation of the latter in a simulation environment. Relationships with two alpha customers who have agreed to set up pilots Integration of the alpha customer database with eligibility checking Development of a rich web application that automates the task of eligibility checking before appointments and generates a report that makes focusing on ineligible patients easy. Statistical evidence for almost a month of operation shows that 5.7% of appointments were for ineligible patients. This was detected before services were rendered instead of after the fact, which had been the norm. Session tracking in SMS. The conceived method was tested in a simulated environment and yielded positive results as it awaits testing in a production environment. Clear identification of further commercial applications, beyond patient eligibility, that take advantage of a technology with a strong presence (SMS). These features are in line with the direction of MGI’s business strategy and are anticipated to create an even more appealing offering to providers. Appointment reminders which ought to result in reduced missed appointments Billing reminders, which should result in a reduction of the average time in accounts receivable Medication reminders, which should result in better medical outcomes Medical Condition Management, which should result in better medical outcomes Consent via SMS which should add to laboratory efficiency. Summary – broader impacts: As Health Care Reform changes the market, the economics of all players in the Health Care System will be altered. Many providers, particularly Rural and Urban clinics, operate on very narrow margins, and will need to be more rigorous about their own business practices in order to continue providing services to their underserved communities. Our alpha test in a rural community in Western Nebraska identified a material opportunity to retain revenue; annualized , this revenue is equivalent to two nurses’ salaries. By using a universal mailbox for Health Care communication, Providers will optimize their communication with their patients on Financial matters or Medical matters. Financial: Many US Providers operate with single-digit (or lower) margins. At the same time, 6% of Health Insurance claims in the US are declined because a patient’s insurance was not valid (easily checked), and the average medical practice has 15-30% of total revenue in Accounts Receivable at any time. (By comparison, in the more efficient retail sector, only 5% of revenue is in A/R.) This inefficiency hurts the ability of Providers to invest in new services and personnel, and consequently affects medical outcomes. Medical: Patients who have a clear understanding of their after-hospital care instructions, including how to take their medicines and when to make follow-up appointments are 30 percent less likely to be readmitted or visit the Emergency Room than patients who lack this information.
