The greatest problems we have today regarding the specific transactions cited in the law are related to the receipt and processing of claims, encounters and referrals. For claims and encounters, we currently receive transactions in multiple formats that can vary by specific providers, and in some instances individual providers deal with multiple formats. This environment requires significant processing support, both technical and manual in order to ensure timely and accurate payment to the provider of care. Limitations of the current formats inhibit our ability to analyze the quality of care in a manner that exceeds current industry standards. Providing a means to effectively gather data in a consistent format will enhance our ability to provide quality care while reducing the burden on providers to supply that information.
Referrals are an integral part of our managed care processes.
The current processes in place require significant manual processing, and we continue to move aggressively toward EDI solutions for these transactions. In doing so, we need to view the implementation of all transaction sets and recognize the interdependencies inherent in the overall process. The timing of the receipt of a referral along with the quality of the data elements are critical to the delivery of high quality care and the processing of subsequent transactions such as claims and encounters. Claim attachments are another major concern. Current technology exists to process many attachments electronically, but the implementation is severely restricted by the lack of standards for both content, format and telecommunication protocols.