What do you consider a "real-time" transaction?

Image Courtesy of Eligible

There's a fantastic write-up from Eligible, a company I've had the pleasure of working with recently, on the state of "real-time" transactions in the health care sector.

With the passage of The Health Insurance Portability and Accountability Act of 1996 (HIPAA), our government created a set of standards defining the kind of transactions that your doctor, your insurance company, Durable Medical Equipment Providers (DMEs) and a whole host of other participants in the health care sector carry out while delivering your health care to you (and making sure it's paid for...)

Image Courtesy of CMS

While most of the attention around HIPAA tends to be focused on the Security, Privacy, and Breach of Notification Rules, this legislation was the first time any of the participants in the health care sector attempted to create a single unified standard defining what types of information should be included, for example, when a doctor's office sends an electronic request to an insurance company to verify what kind of coverage you have before providing you with services.


There's quite a few other standard transactions included in HIPAA, of course, but the one we all most often FIRST come into direct contact with (through our physicians anyway) is what's called an Eligibility Inquiry.

As you might imagine from the name, this is when your doctor (or pharmacist, or medical equipment supplier, etc...) sends an electronic request to your insurance company asking...hey, does this person that's asking me to provide services / products actually have insurance? and what does it cover? and what is their co-pay? how about their deductible? ... you get the idea...

So here's the funny thing, at least from my perspective.  HIPAA mandates that your insurance company returns a response in less than 20 seconds.

20 SECONDS

And ok, I can admit that I was freshly out of high school when that law was passed...and 1996 was still the age of dial-up modems (I think I had a blistering 28.8 kbs, yes kbps, US Robotics Modem, which was screaming in those days...) but can you imagine waiting 20 seconds for a web page (of ANY kind) to load today?

Of course not.

Image Courtesy of CMS

The CMS is sort of a baseline for these kinds of requests & responses, since they manage these transaction types for Medicare & Medicaid patients and they provide a status page that gives you an idea of how they're handling the transaction load at any given moment - check it out at http://www.hetsstatus.com/

That page indicates that the CMS considers a 5 second response time "responding normally to all eligibility requests" and that does seem fair on today's modern web.

But as Eligible notes in their post, they've had to create a feature in their system to automatically kill any eligibility inquiry from one of their customers to an insurance provider that lasts longer than 20 seconds (and they even re-submit it for their customers at no cost, which is a killer feature, by the way).

Basically, this means that transactions times are longer than 20 seconds often enough, during certain periods, that they found it cost effective and a valuable enough service to their customers to develop this feature, test it, and support it.  Which led me to think that this is a fairly common issue among some statistically significant portion of their customer base.  Eligible's CEO recently also offered a nuanced analysis of the situation on her blog.

This opinion of mine is due in no large part to a significant amount of anecdotal evidence I've accumulated through the last year of being one of their customers - designing software using their API, working with their Support & Engineering teams, interacting with their management team, etc...

Katelyn Gleason discussing Eligible's RESTful API for HIPAA X12 EDI Health Care Transactions via YouTube

Your experience may differ, but I've found Eligible to be a company with a really bright collection of talented people who are genuinely quite passionate about the problems that they help their customers solve.

They've gone out of their way with us to share their knowledge and hard-won expertise working with thousands of insurance plans to help us develop solutions that make it easier to interface with insurance companies using modern web development technologies and a RESTful API.

Eligible is a well-funded graduate of Y Combinator (YC S12) and is led by a smart, driven, and customer-focused CEO Katelyn Gleason (who is not only active on GitHub, but has on many occasion jumped on calls with my engineering teams and also our Executives to work through technical / business development issues we faced during our rollout).  So has the rest of Eligible's truly talented team of professionals...I'm just saying it's not often you can get that level of support when working with a technology partner.

Image Courtesy Katelyn Gleason

She is joined by cofounders & staff who are equally smart, dedicated to their customers, and just in general exciting to work with - their enthusiasm is infectious - I can genuinely not find much to complain about when most of my day is spent with partners & people who are smart and gets things done.

But then I remember that the main point of this post wasn't just to praise Eligible, but to bemoan the fact that we DO live in a world in 2014 where we have to wait sometimes for up 20 seconds to make a simple HIPAA 270 eligibility request and receive a (271) response.  If Eligible is feeling this pain for their customers, there are others feeling this pain as well.

TL&DR: this problem is WAY too prevalent today - technical solutions to these problems exist, they just need to be implemented.

Of course, if you also happen to be in the business of developing software in this space, you should probably be using asynchronous calls in your web or mobile applications when you're submitting this kind of query (to Eligible or any other clearinghouse)....

I know I wouldn't be waiting around 20 seconds to see if your software provided a response if I was the one using it.  I have better things to do with my time, and so does EVERY one else.

Here's to hoping that the passage of the Affordable Care Act kickstarts some much-needed investments in the infrastructure used by Hospitals, Insurance Companies, Physicians, and all the other participants in the multi-faceted US Health Care System.

We are doing our best at ACA Ventures / Ameda Direct to invest in these kind of technologies to help improve the experience our customers have when they engage with their physicians, suppliers, and insurers to address health care needs of their families.  Only time will tell what kind of returns these investments yield and which wind up best suited to the most recent changes in the health care marketplace.

Maybe in the next decade we can get all of our participants in the health care system to work together to get these load times down to a respectable 10 seconds....one can certainly hope.

After all, providing more efficient access to our health care information and speeding up and bringing down the cost of providing health care to Americans is a great idea!

I am not 100% sure I'd be willing to hold my breath for that long, though...do you realize how long it would take my doctor to figure out if I even have health insurance if that didn't work out????