The Health Care Payer Role in HIEs

Health Data Management had an interesting article in the June 2009 issue on the payer role in HIEs. The core philosophy of health information exchanges (HIEs) is to bring together industry stakeholders to facilitate the appropriate sharing of patient data throughout a community, region or state. Several steps need to be taken to create widespread movement by the health plans to support heath information exchange.

These include better as is, and to be process improvement, an open dialogue between payers and providers by skilled facilitators, and a skilled team of subject matter experts at payers who understand ICD-10, X12 5010, and the impact on and modernization of the claims systems and adjudication process.

From Health Data Management, …But while HIEs have worked for years to get established, a major stakeholder – health insurers – remains absent or a marginal player in many initiatives. Some health plans still are waiting for a viable business model that will justify a major investment in HIE initiatives. Others, particularly national payers, don’t have a large market share of covered members in many of the regions that have an HIE. These payers and even regional insurers also often can’t get involved in HIEs if their employer clients aren’t sold on the idea of data exchange.

A small number of payers, however, are knee-deep into HIE initiatives. Chattanooga-based Shared Health, serving all of Tennessee, launched its HIE using claims data from two major insurers to provide physicians with a basic summary of care. Moreover, Blue Cross and Blue Shield of Massachusetts spent $50 million to wire up physicians with EHRs in three towns and get HIEs established there. We have answered questions that these systems can scale and how to implement them, says Steven Fox, vice president of provider network management at the Blues plan. We view it as a worthy investment and successful.

The HIE is a fundamental component of Obama’s plan to make health care more efficient and affordable.

Michael F. Arrigo

Michael is Managing Partner & CEO of No World Borders, a leading healthcare management and IT consulting firm. He serves as an expert witness in Federal and State Court and was recently ruled as an expert by a 9th Circuit Federal Judge. He serves as a patent expert witness on intellectual property disputes, both as a Technical Expert and a Damages expert. His vision for the firm is to continue acquisition of skills and technology that support the intersection of clinical data and administrative health data where the eligibility for medically necessary care is determined. He leads a team that provides litigation consulting as well as advisory regarding medical coding, medical billing, medical bill review and HIPAA Privacy and Security best practices for healthcare clients, Meaningful Use of Electronic Health Records. He advises legal teams as an expert witness in HIPAA Privacy and Security, medical coding and billing and usual and customary cost of care, the Affordable Care Act and benefits enrollment, white collar crime, False Claims Act, Anti-Kickback, Stark Law, physician compensation, Insurance bad faith, payor-provider disputes, ERISA plan-third-party administrator disputes, third-party liability, and the Medicare Secondary Payer Act (MSPA) MMSEA Section 111 reporting. He uses these skills in disputes regarding the valuation of pharmaceuticals and drug costs and in the review and audit of pain management and opioid prescribers under state Standards and the Controlled Substances Act. He consults to venture capital and private equity firms on mHealth, Cloud Computing in Healthcare, and Software as a Service. He advises ERISA self-insured employers on cost of care and regulations. Arrigo was recently retained by the U.S. Department of Justice (DOJ) regarding a significant false claims act investigation. He has provided opinions on over $1 billion in health care claims and due diligence on over $8 billion in healthcare mergers and acquisitions. Education: UC Irvine - Economics and Computer Science, University of Southern California - Business, studies at Stanford Medical School - Biomedical Informatics, studies at Harvard Medical School - Bioethics. Trained in over 10 medical specialties in medical billing and coding. Trained by U.S. Patent and Trademark Office (USPTO) and PTAB Judges on patent statutes, rules and case law (as a non-attorney to better advise clients on Technical and Damages aspects of patent construction and claims). Mr. Arrigo has been interviewed quoted in the Wall Street Journal, New York Times, and National Public Radio, Fortune, KNX 1070 Radio, Kaiser Health News, NBC Television News, The Capitol Forum and other media outlets. See and for more about the company.

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