By Christopher Guadagnino, Ph.D

Published November 2000

• React to this article in the Discussion Forum.

Kenneth R. Melani, M.D., is executive vice-president of strategic business development at Highmark Blue Cross Blue Shield.

PND: Can you describe Highmark’s new on-line interface for medical practices ?

KM: NaviNet is a software application that enables the physician office to electronically communicate with the health plan and, in future releases, to communicate with other health care providers, hospitals, other suppliers, home health, pharmacy and eventually individual patients. NaviNet uses the Internet to enable a physician office to do a number of transactions with us that they previously may have had to do through other means, like a fax, a telephone or paper forms and mail submission. Currently, the major functions are referral authorization, claims submission and status, patient eligibility and benefits, and information to the physician office such as diagnosis and procedure codes, other physicians and providers for referrals and recommendations, fee schedules for procedures or services in the various programs that we have. There is also the ability to have content available to help physicians and members with their decision-making processes, such as medical policy and formularies. At this time, even though the physician can use the system, the services are presently designed for the front office staff, with their workflow process in mind, to help them interface with the health insurer. Future releases will have capabilities that physicians themselves will use. Highmark is a customer of NaviMedix, a technology development firm located in Boston offering the software application, under a contractual relationship. In addition to that, we have a small amount of equity in the parent company NaviMedix. NaviMedix also has relationships in Connecticut, New Jersey, New York, Massachusetts and Ohio.

PND: How would the system work?

KM: The office staff would come in in the morning, turn on their personal computer and see an icon that says, "Highmark/NaviNet." They would hit the icon and up would come a screen that asks them to provide their identification number, which is unique to that user, and a password. They would then get into the system and be able to conduct a variety of actions with Highmark, or other payers, on the back end in various formats. If they hit the referral icon, a form would come up and they would enter a patient’s last name, full name, identifier, address—whatever information they had. They can fill in clinical information with the help of prompts and automatically pre-populated pieces of patient data on the form. So, if they had a diagnosis, they could look up a bunch of diagnoses, type in partial name of a condition and the system would help them fill out the form.

The nice thing is that it doesn’t matter who the insurance carrier is, the form is filled out by the staff the same way. Highmark’s form might be different from Health America’s form which might be different from U.S. Healthcare’s form, but the staff doesn’t have to see that. The staff sees one way of doing business. When they’re done putting in the information, they hit a key and that information is then transferred to whatever mode the insurer is capable of receiving it in. So, all that information would be sent to Highmark and would populate Highmark’s systems in a way that we capture that data for our purposes. We would have, say, a referral now automated into a database, on-line and available. When that patient shows up to the referring physician’s office, the staff hits the referral icon, enters the patient’s name and they see if a referral exists for that patient to be seen by that specialist physician. It’s all on-line now. They don’t have to call Highmark. They don’t have to have paper. They don’t have to fill out three different forms. It’s all real time, on-line.

PND: What about diagnosis and procedure code information and referring physician lists?

KM: Same screen. It’s all right on that PC. You hit another icon to go into the diagnosis and procedure code area. For instance, the staff types in the word, "tear," hits a button, and up comes every diagnosis with its code that has the word "tear" in it. So you could see meniscus tear and tear duct. By looking at the modifiers, the staff can begin to home in on what the proper code is for the procedure that the physician did or would have like to have done on a referral and authorization. It can be used for billing purposes, for referral and authorization purposes, or simply to look up the fee schedule for a particular service based on that code and the insurance program under which they’re billing it. All of that information is right there at the fingertips of the office staff.

PND: What kind of training is required for office staff to use this system?

KM: Our provider relations staff have been trained in the use of the tool so they can work with the office staff on an on-going basis. NaviNet has a full staff in the field here in Pittsburgh doing training. We go in the office and make an initial assessment of their hardware capabilities to support the program. We help them get that hardware in place if they don’t have it. Once that’s done we then go in and install the software and train the office staff on its usage. Typically we’re there for a couple of hours showing them how it works and how it can be used. There’s also on-line help and tutorial that’s available. We have a call desk that’s available six days a week on extended work hours. And if they need to, they can call our provider relations staff and we’ll go back and help them face-to-face. So we have a very thorough support system for this.

PND: What range of practice settings can it be used within?

KM: It could be used in all provider locations, from a solo practice setting to a large, multi-specialty group setting. We’re going to install it in the hospitals starting the first of the year. We already have some installations in other health care provider sites. For example, you could use it when the lab service company has a patient come in and wants to see if there’s been a referral or an authorization made. The next release of the system is to get technology in the hands of the physicians so they can begin to do prescription writing, lab order entry, diagnostic testing order entry, and even order entry for the office procedures and hospital-based rounds and procedures that they perform. That could just simply be put into a palm top device automatically set to a practice management system, the insurer, the lab, the pharmacy. That’s where we’re going in early 2001 and through the course of 2001.

PND: How many physicians currently have this system?

KM: We started implementation in the marketplace at the very end of August and we have over 400 physicians and their practices using the system currently, from which we’ve had over 16,000 inquires through the system. Tentatively, by the end of this year, we are targeting to have over 4,500 physicians on the system principally from western Pennsylvania. Our goal is to move out to central and eastern Pennsylvania in the first part of 2001 and, by the end of 2002, to have 26,000 physicians using the system. We’ll start adding functionality to the system that is more physician-specific, such as pharmacy and order entry, in 2001 and there will be capabilities that link the physician with the patient in the later part of 2001. We’re looking at being able to do real-time claims adjudication. We’re not looking to replace the practice management system, although that is available if they would like. As for the physician-patient interface, the kinds of things we’re talking about is the ability to do appointment inquiry, scheduling, sharing diagnostic testing results and allowing the patient to e-mail the staff and the physician with questions. This is all in discussion and will be practice-specific based on what they want to do in the marketplace.

PND: How can the system be used by other health insurance companies?

KM: NaviMedix is currently talking with other health insurers in the Pennsylvania marketplace and those insurers will have the ability, if they so desire, to link into the NaviNet system. That would require them to work with NaviMedix to create an interface between their back end systems and the NaviNet front end system. It would require some expenditure to make that happen, although it’s not that much, and it would also require them to work out with NaviMedix a fee structure for support of the applications.

PND: What would Highmark’s role be if other insurance companies link with NaviMedix?

KM: We believe that, for this thing to really be successful for all of us, it has to be payer neutral. So, we are encouraging NaviMedix and encouraging other payers to consider coming on board and help physicians and their office staff to solve the hassle that they face in their practices today in the marketplace. We’re in discussion with our sister blue plans in the state, but there are some non-blues that we’re in discussion with too. NaviMedix would like to have other plans in the early part of 2001. We made this happen in 12 weeks: completed a contract with NaviMedix, completed the design with all the interfaces and we were in the marketplace. So, that’s the time-frame you’re looking at if any other insurer is willing to put the effort into making this happen with NaviMedix.

PND: Are you working with any medical societies or physicians to help develop the system?

KM: Yes. NaviMedix in Boston has worked with physician groups extensively over the last two to three years to design this but, since the first phase for us is an office staff product, we’ve worked closely with the office staffs. We have used focus groups throughout western Pennsylvania. We worked with the physician community by bringing out the software and having them work with it and give us comments. We’ve gotten feedback from the county medical society and even talked with the state medical society about it and demonstrated the capabilities. As we get into the physician side, right now we have about 130 physicians pilot testing the hand-held device in the marketplace and giving us feedback. As we get into the physician part of it we’ll be working more closely with organized medicine and physicians to help tell us what it is they need and how we can best make that happen.

PND: In addition to the application expansions you’ve mentioned, do you anticipate adding any other functions such as physician profiling?

KM: Yes. We have a lot of information available that we’ve been working on to help physicians understand their practice better and their patients’ needs better. In 2001 we are looking at making that information available electronically. Physicians will be able in the later part of 2001 to access and manipulate this data for their own purposes. They could generate a customized report to see how they’re doing in specific areas. For instance, if you want to see any patient in the office from Highmark who had a diagnosis of meniscus tear, you can do that and start to look at information related to that. It will actually be a practice management, not just billing, capability if they desire to use it that way.

PND: So this tool can be used to meet Highmark’s goal of reducing variation in physician practice patterns?

KM: Absolutely. I think the whole gist of the initiative is to let physicians and patients be more accountable for health care decisions. Get information in the hands of patients and physicians so they can make better and more informed decisions and get out of the micro-management process that we’ve historically done.

PND: Does the system log the date in which a claim is received and will there be notification of whether it’s a clean claim?

KM: Right now, the system will take claims and simply transmit them back to the health insurance carrier. So, a practice can pull claims from the practice management system and just transmit them via the Internet to the health insurance carrier. If you don’t have a practice management system, there is software within the system to allow you to enter the information for a claim and then send that to the carrier. There are some edits built in that will make sure you’ve entered the proper date, that a diagnosis code is filled out, that there is the right number of elements. As far as it being a clean claim, meaning that you’ve done everything right and you’re going to receive payment, that it meets all the criteria related to medical policy, that the benefit is there, that the patient’s co-pay is correct, you will know within 24 hours. If the referral and authorization isn’t there, then you’ll be able to see that the claim has been pended because we’re searching for a referral and authorization. Every day you can look at it and determine its status. But if everything’s there, within 24 hours of hitting our system, that claim will have been turned around and you’ll know what the payment reconciliation is. You can go back and see what’s happened with all claims as far back as the last three years in the database we’ve provided.

In 2001, we will be building logic into this so that there will be real-time claims adjudication by which you will get notification if a certain thing hasn’t been filled out properly. It will even go further than that: it will start to match the claim up against the benefits, up against the history files. It will actually conduct that transaction real-time so that when you finish it, you’ll know exactly what you should be receiving in remuneration and that you will receive it.

PND: What are other system benefits to Highmark?

KM: We’re eliminating a lot of more costly processes. When you have to do things by phone or by fax or do things manually, there are definitely cost savings if you can do them electronically. Cost isn’t the only thing. We’re hoping that our members and our physicians see Highmark as having provided some value in the marketplace. We do pay the physicians and hospitals. We do work with them on contracting. But we also should be able to provide them with some capabilities that help them in the marketplace. So, we want to really build our relationship with our members and with our providers, and we hope this does it.

PND: What are specific advantages of the system to patients?

KM: If you’ve got a physician whose life is made easier and you’ve got better information in their hands, not only do you have a happier office staff and physician and therefore happier patients, but you also have a better quality of care being delivered. We think that’s the big benefit. It’s using technology to make care easier to access, make life easier for the physician, get rid of some significant hassle and let us have better patient outcomes.

PND: Are there plans to make the system mandatory?

KM: Not at this time. About 80 percent of our claims are submitted electronically at this point in time. So I think one would have to be honest and say, at some point you can’t support multiple technology. It becomes cost prohibitive to do that. We have to be responsible to the customers and even to the providers. We don’t want administrative costs to consume an inordinate amount of the health care dollar. So as low as we can get that, that’s our intent. At some point we’ll have to make a decision on which modalities we continue to support. With this application we’re going to be eliminating some of the older electronic capabilities we have in the marketplace. Eventually we hope that everything will be paperless, but we want to see acceptance in a non-mandatory way. We want to iron out the kinks if there are any. And then we’ll make some decisions periodically as we go along, in concert with the physician community.