Should Payers Have Access to Your EMR?

How many insurance companies have viewing access to your electronic medical record (EMR)?

And with that access, do you see a difference in their behavior, compared to others? 

We have recently embarked on the usage of a new EMR across our organization. As we have implemented that EMR, we have removed viewing access from many payors. There is a much longer story, and we are implementing a portal for them to use, but I think about where we were and where we have come to, and I just thought that today I would touch briefly on some thoughts of having insurance companies with viewing access to your EMR. 

I wonder, if you have companies that have such access, can you answer a few questions for me?

1. How does the notice of admission get communicated? And is that the time that starts the clock for the company to begin the authorization process? Or does the clock start when they first access the EMR?
2. Do you receive your authorization numbers more quickly for your inpatients? Do you have that number in your billing system before discharge, in order to file claims in a more timely fashion?
3. Does the company reach out to your physician advisors to discuss cases, or do you still need to be the conduit to get that set up?
4. Does the insurance company ask for any involvement on any cases that may be at high risk for readmission? Do they really partner with you on those cases?
5. Who is it at the insurance company that is accessing the record? Is it someone that is truly trained in your system? What does their access look like? Is it someone trained in utilization management (UM)?
6. Do they review the agreed-upon criteria set that your UM team has run, or do they run it again and ignore what your team has done? Does your UM team even look at these cases? If not, I might suggest you review your responsibilities to all patients in your care in the Centers for Medicare & Medicaid Services (CMS) guidelines for UM.
7. If the company does not reside in your state, are they aware of any other state regulations that may come into play?
8. What was their denial rate prior to access versus after access?
9. Does the access help with realizing better quality outcomes and better reporting from the company?
10. Do you have the same access into their claims system as they have into your EMR?  I mean, can you see the claims processing for your claims? 

I am sure there are more questions I could pose to you, but I think this should be enough to see if that relationship is a win for the insurance company, a win for the patient who has that insurance, and a win for the organization.

EDITOR’S NOTE: To respond to Mary Beth Pace, please send her an email:
pacem@trinity-health.org