Critical Innovation In Healthcare Claims Processing: athenahealth CEO Jonathan Bush (Part 4)

SM: You have innovated a rules engine that drives claims filing, which I am assuming has a bunch of codes and other data you have to file against for the claims to be processed. Would you classify what you have done as an expert system?

JB: An expert system intends to imply artificial intelligence whereas ours is actual intelligence, but yes, it could be considered that. It becomes expert because we teach it new things every day although we have not figured out how to get it to teach itself.

SM: Your rules enhancement is entirely hand-coded?

JB: That is correct. It involves business trips out to health plan headquarters, statistical analysis, and some automated algorithms that look for similar claims. If we can find a range of similar claims that have all been denied, then perhaps there is something deeper we can explore.

SM: You still have a master database of rules against which physicians can file their claims, and from the sounds of it you have a database that is very well cleaned.

JB: That is exactly right. Physicians don’t actually file their claims, they just do their work. The rules engine is sitting under the surface of every step. It sits inside the scheduling module, so if you make an appointment for somebody that requires an authorization and we find that you do not have an authorization in your authorization file, it will alert you right then.

SM: Help me understand the interface between you and the practice management system. Are you the entire practice management system for the physician at this point?

JB: That is correct. We handle registration, scheduling, check-in, and check-out. There are two levels of service: collector and clinicals. If you have both, then everything that happens in the exam room and all the orders, results, follow-up with the laboratories, and posting of the results that come back from the laboratories including those which come back on fax. We are the only healthcare IT company who deals with the portion of health care that is not online. That turns out to be most of healthcare.

A doctor who just spent $50,000 on electronic medical records has not changed the fact that every laboratory that he or she may use has not gone and bought their EMR, thus all the results they receive will come in via their fax machine. That puts them in an awkward predicament because now someone on their staff has to sit there and digitize it.

We actually forward the practices fax line to our data center and automate those connections as part of the service in the background. There are a few laboratories that cannot automate anything, and in those cases we just handle the paper for the doctor in the background. We layer on optical character recognition and queuing theory to approximate the accuracy and speed of an electronic connection. What we have emerging in the background, without anyone paying for it directly, is the first every national health information backbone.

SM: What kind of market penetration do you have?

JB: From the physician point of view we have about 2% of the market share. There are 700,000 physicians in the US, 600,000 who we believe practice medicine. We have about 13,000 MDs and 19,000 medical providers. We can send a claim electronically to 85%-87% of insurance companies, which is more than anyone else. We can receive remittance electronically from about 75% of insurance companies. We can receive results from 15% of the nation’s labs. The rest we have to go out and handle via a queue of PDF images that come in over the fax line. Little by little those percentages have been going up every year.

This segment is part 4 in the series : Critical Innovation In Healthcare Claims Processing: athenahealth CEO Jonathan Bush
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