automating healthcare payment and claims remittance processing - systemware's medical banking...

Automating Healthcare Remittance Processing

TAWPI Healthcare Payment Automation Summit

Chicago 9/14/09

Gordon Sellers Director, Healthcare & Medical Banking Solutions

gordon.sellers@systemware.com

Providers Landscape

•  7000+ hospitals, clinics, surgery centers, etc. •  450,000+ physicians in private practice

–  Half in practices with more than 5 physicians

•  Average 30% first pass denial rate per charge code –  Half due to eligibility issues

•  Average administrative cost per submitted claim –  $10 to $12

•  Average total administrative cost per secondary claim –  $8 to $10

•  Administrative cost for appealed claims –  Can surpass $60

Source: Healthcare Financial Management Association

Why Medical Banking

•  Currently banks provide: –  lockbox services such as deposit of payments –  imaging of checks –  imaging of paper EOB (some)

•  What banks could provide: –  Data conversion

•  of paper EOB’s into EDI 835 files for posting to Provider systems –  Balancing

•  of claimed amount with paid amount minus any adjustments –  Process automation

•  to reduce error rates and processing cost for Providers –  Visibility

•  into the relationships between claims, payments and deposits •  Transactional discipline

Medical Banking

Extended HC Lockbox

•  Medical Banking Application –  Capture & indexing of EDI 837 files –  Converts paper EOB’s into EDI 835 files –  Capture & indexing of EDI 835 files –  Automatic matching between EDI 835 files & EDI 837 files at the

claim and/or service line level –  Output of targeted file for upload into PMS at Provider –  Secondary / Tertiary claim preparation & submission –  Exception Management workflow queues –  Reporting

•  Bank Administration Portal –  Set up & Administration of Providers –  Transaction Billing Report

Online Providers Experience

•  Provider Portal (Bank Branding)

– Manage processing exceptions •  837 /835 matching •  Secondary match to primary EOB image •  Secondary match to 835

– Download posting file – Research denials for resubmission or

secondary – Dashboards and report generation

Copyright © 2009 Systemware, Inc. 13

Medical Banking

•  What banks SHOULD provide: –  Data conversion

•  of paper EOB’s into EDI 835 files for posting to Provider systems –  Balancing

•  of claimed amount with paid amount minus any adjustments –  Process automation

•  to reduce error rates and processing cost for Providers –  Visibility

•  into the relationships between claims, payments and deposits –  Transactional discipline

•  banks have are good at this healthcare (providers) are not