Availty, L.L.C.

By offering HIPAA-compliant transactions and other functionality at no charge to providers, Availity has streamlined administrative workflow, reduced costs, and ultimately improved the patient experience.

Situation

Improve efficiency and reduce the administrative complexity in the health care industry. That was the mission in early 2001 when Blue Cross and Blue Shield of Florida, Inc. (BCBSF), an independent licensee of the Blue Cross and Blue Shield Association, joined forces with Humana Inc. BCBSF offered a product called Virtual Office, while Humana offered Kinetra and e-Humana applications. However, to meet the market demand for a multi-payer solution that was Internet-based and HIPAA compliant, BCBSF and Humana, two long-time competitors, worked together to create the foundation for Availity. It occurs seldom, if ever, that two competitors form a partnership with a common vision, a common goal, and a common solution; however that’s exactly what occurred.

Taking advantage of an established business process with a roadmap for the idea, a business concept to business model, the team worked to establish Availity, L.L.C. as a formal entity in February of 2001. Physicians and hospitals who once had to access a separate portal for each health plan were finally able to log on to the Availity® Health Information Network, a secure web portal, to reach multiple health plans.

In 2006, Health Care Service Corporation (HCSC) entered into the joint venture with BCBSF and Humana whereby HCSC contributed the assets of their wholly owned subsidiary, The Health Information Network (THIN), with Availity to become one of the owners of the Availity organization. The new Availity organization is not only one of the nation’s largest EDI clearinghouses, but one of the most advanced health information exchanges in the country.

Solution

Physicians, hospitals, and other health care constituents who once had to access separate systems, phone numbers, or use other manual means to transact with multiple payers, can now log on to the Availity® Health Information Network, a secure web portal, to conduct routine administrative, financial, and clinical functions.

The goal was to create a multi-payer, multi-provider solution that would remove administrative inefficiencies, streamline provider workflow, and accelerate the exchange of information between health plans and health care professionals. Moreover, to offer access to all health care providers, it had to leverage the Internet as a secure, neutral, HIPAA-compliant transaction exchange – at no or minimal cost to providers. Because health care is best managed locally, the ultimate goal of Availity was to strengthen the community by bringing health plans and health care professionals together in select regions to better serve the health care needs of those regions.

Availity supports the HIPAA transaction set—claim submissions, claim status inquiries, remittance, eligibility and benefits inquiries, and authorization and referral submissions and inquiries. Availity also supports real-time claim adjudication for those payers with back-end systems that support it. This means if the claim passes through all edit files successfully, it can adjudicate and return information to the health care provider, such as amount paid, in seconds. This real-time connectivity between Availity and health care stakeholders has revolutionized the manner in which electronic administrative transactions are performed. Additionally, integration of these transactions with practice management and hospital information systems enables real-time population of accounts receivables and patient records.

In May 2006, Availity formally entered the clinical space by launching the Availity® Care ProfileSM, an electronic health record sourced from claims and other information sources. That same year, the CareCalcSM service was also launched, which helps determine a patient’s financial responsibility in real-time. Responses are based on member benefits, provider contractual allowances, deductibles and benefit maximum accumulators at the time of inquiry.

In 2007, the company entered the financial space by launching the CareReadSM service, which allows health care providers to swipe a patient’s magnetic stripe-enabled member ID card through a three track-enabled card reader connected to the computer and read the information contained on the card. Availity has plans to support financial transactions, such as debit and credit charges, with the CareRead service.

These services were launched to support Availity’s basic health plan transactions and offer a true “one-stop shop” for a myriad of health care transactions. Availity plans to offer other value-added services as the market demands and is positioned to effectively utilize them.

Better Health and Lower Costs

By offering HIPAA-compliant transactions and other functionality at no charge to providers, Availity has streamlined administrative workflow, reduced costs, and ultimately improved the patient experience. When the Availity Health Information Network was first introduced into the health care market in September 2001, very few physician offices had internet access, and almost none had experience using internet-based applications. From the ground-up, the Availity Health Information Network has been designed to benefit all health care providers, including physician offices, from single providers to multi-specialty practices; hospitals and integrated delivery networks; pharmacies; laboratories; and ancillary providers.

Availity now serves more than 28,000 provider offices and 950 hospitals in the states in which we are focused. This has resulted in Internet exposure to a majority of health care providers in those focus regions, which has revolutionized the industry from batch processing to real-time information exchange. This, in turn, has enabled most health care providers to modify their workflow to achieve cost and time savings, not to mention improve their relationships with their patients. In fact, Availity has directly impacted providers’ broadband internet usage in Florida from less than 40% to more than 90% and has migrated the claim processing timeframe from post 5:00 p.m. to prime time.

In keeping with the successful trend since the company’s inception, 2007 has been another stellar year for Availity. Availity continues to be adopted by health care providers in Oklahoma, New Mexico, Texas, and soon, Arizona, with the addition of Blue Cross and Blue Shield of Arizona as a partner. The Availity web site now averages more than one million hits per day and processes an annual run rate of more than 400 million transactions.

Availity is the preferred EDI claims clearinghouse for Humana nationwide and for Blue Cross Blue Shield of Florida. Humana designated Availity as their national primary electronic gateway in early 2004, while BCBSF did so in 2003. To meet this challenge, Availity migrated an annual volume of more than 20 million transactions from 39 clearinghouses across the nation. Thanks to the efforts of a phenomenal team, this project was finished on time and within budget. Availity is now embarking on the same migration with HCSC, with plans to complete the effort in early 2008.