High-profile senators including Hillary Clinton continue to lobby for legislation requiring U.S. health care clinics to upgrade their ancient pen-and-paper reporting procedures to automated electronic medical record systems.
Clinton estimates that digitalizing essential medical records will save a staggering US$77 billion.
Ontario Health Claims for Auto Insurance (HCAI)
North of the American border, a group of Ontario auto insurance companies have collaborated with medical practitioner associations and government parties like the Financial Services Commission of Ontario and the Ontario Ministry of Finance to develop an electronic system for the provincial auto insurance industry called Health Claims for Auto Insurance (HCAI).
Effective February 1, 2008, all auto insurers and medical care providers were obligated to use the new system for registering and invoicing auto insurance claims. Just six weeks later, the Ontario Superintendent of Financial Services Bob Christie suspended the creation of new electronic claim forms because the new HCAI system was unable to cope with extremely high processing volumes.
While peak-period technical issues have yet to be resolved, the HCAI system still presents a fascinating case study in how technology can result in significant benefits in auto insurance claims processing.
HCAI Automated Electronic Forms
Once up and running, the HCAI system enables medical practitioners to electronically register their facilities and patients, and send standardized claims forms for pre-treatment estimates and invoicing via a central repository. These standardized PDF forms include:
- Treatment Plan (form OCF-18)
- Application for Approval of an Assessment of Examination (OCF-22)
- Pre-approved Framework Treatment Confirmation (OCF-23)
- Standard Invoice (OCF-21).
Insurance company claims adjusters use the HCAI system to approve or decline claim pre-treatment plans and invoices online.
How Automated Claims System Works
After an insured claimant first informs an insurer about suffering car accident injuries, an insurance company employee signs onto the HCAI website, then creates claim and claimant records on the system.
The insured claimant visits a medical practitioner for an initial assessment of required treatment. That practitioner may work at a private practice, health care clinic or rehabilitation facility. If the insurer requires, the medical care provider will sign onto HCAI to create a treatment plan using electronic form OCF-18. Some medical practitioners have in-house application software than can manage OCF-18 treatment plan reporting to HCAI.
An insurance company claims adjuster then records a decision of approved, partially approved or declined right on the online treatment plan form OCF-18.
HCAI Electronic Invoices
If a required treatment plan is approved, the medical care provider creates an invoice using standard form OCF-21 on HCAI to send electronically to the insurer.
An insurance company claims adjuster verifies the online invoice, and records a decision of approved, partially approved or declined right on the invoice form.
Like treatment plans, the medical care provider can immediately view insurer decisions on invoices online.
HCAI Benefits and Advantages
Medical care providers who are unable to use the HCAI website are forced to complete the old, paper-based Ontario claim forms. Many manual calculations are required, thus the process is prone to error and subsequent delays.
In addition to automating error-prone and time-consuming workflows, the new automated claims system offers the following benefits.
- Medical care providers receive faster, more accurate cashflows from auto insurers
- Insurers instantaneously access correct, complete and consistent data on which to base claims adjudication decisions
- Government regulatory agencies including auditors and compliance officers can better monitor auto insurance industry claims through more timely and higher quality statistics
Insurers also have the option to automatically update their payment systems with data extracts from HCAI.
Practice Management Software and Patient Management Systems
While HCAI developers resolve HCAI network load issues, busy medical care professionals can still outsource the automated submission of electronic claims forms to leading business and technology consultants. The HCAI website lists participating vendors that adapt practice management software and patient management systems to communicate with HCAI.
One of these leading software companies, Mantrac Information Systems, has over 30 years of experience developing cost-effective systems solutions for medical practitioners and insurers not only in Canada but in the U.S. and Europe as well.
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