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Will HL7 Create Payer/Provider Symbiosis?

Karen Minich-Pourshadi, for HealthLeaders Media, December 13, 2010

Though it has been a long time in the coming, Hughes explains that portions of this standard are now completed and have been submitted to Health and Human Services for final approval. As of 2004 all payers are supposed to take claims electronically, the problem, however, is that the form in which documents are attached has been undefined and is causing miscommunication and claims processing delays.

Some payers have taken a proactive stance with electronic claims by creating provider networks. These networks are designed to give providers direct access to relevant information on the payer’s system, which enables both parties to share data electronically, perform claims transactions online, and provide centralized technical and billing support. By electronically streamlining the communication process between the payer and provider, these provider networks save time and administrative costs and they eliminate the need to process paper claims. Moreover, these systems allow for both payers and providers to use remote workers affording all involved with additional savings.

However, a uniform approach to how documentation is attached remains to be defined by HL7.
“Right now, there are solicited and unsolicited attachments, and only the payer decides if they will accept them. A payer would rather pay a claim instantly than send it back to ask for more information. Payers don’t want unnecessary attachments—you don’t want four million claims all with attachments,” he says.

While the HL7 standards await final approval, payers and providers must continue to look for ways to make their relationship generate more profit and less waste and strife—true symbiosis is the only way everyone will come out ahead.


Karen Minich-Pourshadi is a Senior Editor with HealthLeaders Media.
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