healthcare payment & remittance · healthcare payment & remittance medical banking - best...
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Healthcare Payment & Remittance Medical Banking - Best Practices
Art Conklin, Director of FirstProxy and Electronic Payment Services
2 Confidential Information
Electronic Healthcare Payment Session Objectives
• Overview of medical banking models in the healthcare payment and remittance marketplace
• Exploring best practices with an eye on:– ROI– Inter-operability– Auditing– Reconciliation
• Context – emerging marketplace
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The Electronic Healthcare Payment Critical Success Factors
• Transaction flow controls• Operational efficiencies,
savings and profitable revenues.
• Reconcile billed to paid.• Reconcile financial to
administrative, the ERA to the EFT.
• Efficient Customer Support
Connectivity is the key
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The Electronic Healthcare Payment Managing the Critical Control Points
• Transaction standards• Systematic reconciliation• On-line ERA management
tools• Consistent operational
practices, such as enrollment
• Linking ERA and EFT • Meaningful adjudication
codes• Purging the paper and
handling
Fitting the pieces together
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Healthcare Electronic Payment Models
• Standard healthcare claim and payment– Provider to Plan to Provider
• Combining the administrative (ERA) and financial payment transactions (EFT)
– Outsourcing payment components
• Consumer driven plans and healthcare funds– Greater member responsibility for selecting services &
allocating payment.
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Claim Payment Life Cycle
Provider
PayerAdjudication
Clearinghouse
PaymentERA/EFT Reconciliation
Claims Submission
Standard Electronic Healthcare Payment Cycle
Clearinghouse ACH
Healtcare service to patient
PaymentRemittance Advice
EFT/Check
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The Standard Electronic Healthcare Payment Model
• Clearinghouses process 835 from Payer to Provider’s
• Payer’s bank processes EFT to Provider’s bank• Support Vendor Intermediaries• On-line management & support tools.• Building partnerships to provide quality, value add
products & services.• Priced to produce savings and profitable
revenues.
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Provider Database
Print and mail
Electronic payment
Combining Administration and Financial Transactions
ERA
ERA
EFT
Reconciled
FirstProxy
USPS
Payer Healthcare Provider
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Combining the Electronic Healthcare Payment’s Administrationand Financial Transactions
• EFT capability through ERA.• ERA-EFT reconciliation.• Single management tool for both payment
transactions.• Consistent operational workflow• Efficiencies multiplied • Fully outsourced payment functions
FirstProxy
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Combining the Electronic Healthcare Payment’s Administrationand Financial Transactions - Challenges
• Realignment of traditional partnerships in managing healthcare payments.
• Slower than expected market acceptance to outsourcing payment function.
• Final completion of Phase 1 of HIPAA Transactions
• Recognition of value equation
FirstProxy
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Electronic Payments in Consumer Driven Health Plans and Funds
Fund Payment Life Cycle
Provider
Fund / Plan Administrator
Clearinghouse
PaymentAuthorization / funds transferFund / plan eligibility – fund withdrawal
Healthcare service to patient
Clearinghouse ACH
Eligibility / benefit verification
PaymentRemittance Advice
EFT/Check
ERA = Electronic Remittance Advice
ACH
Card swipe
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Electronic Payments in Consumer Driven Health Plans and Funds
• Multi purpose benefit card is emerging to handle member payment responsibilities in consumer driven health plans and funds.
– Credit / Debit of accounts– Administrative transactions, e.g. eligibility / benefit
verification.
• Fits into provider workflow.• Newer technology for POS devices permits for
larger data requirements.
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Electronic Payments in Consumer Driven Health Plans and FundsValue Add Opportunities
• Credit funds beyond debit accounts.• Claim submission as component.• Integrated eligibility and benefit verification to
determine who is responsible for what of the treatment costs.
• Advance payment for plan’s payment responsibility.
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Electronic Healthcare Payment Summary
• Electronic payment with value-added services (i.e. Web management tool).
• ERA/EFT combination via strategic partnership.• Multi-purpose benefit card support.• Value add products & services where
opportunities exist.• Priced according to value.
Appendices
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Traditional Electronic Payment Workflow
Payer claims receipt
Claimsadjudication
Accounts Payable
ERA preparation
Payer banking interfaceClearinghouse
batching, consolidation
and/or splitting logic
Payer Gateway data translator
(ANSI 835), ANSI edits connectivity
Payer Gateway data translator
(ANSI 835), ANSI edits connectivity
Payer Gateway data translator
(ANSI 835), ANSI edits connectivity
Payer Gateway data translator
(ANSI 835), ANSI edits connectivity
Clearinghouse batching,
consolidation and/or splitting
logic
ERA preparation
Provider’s proprietary
software posting
PMS posting software
Banking institution EFT transaction
creation and routing
Provider bank
Funds transfer
Network
Provider Accounts
Receivable
Provider claims submission
Reconciliation
Online EPP
Manual posting
ERA/EFT Process
16
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Healthcare Account Debit Flow
Eligibility / benefit plan
Enrollment / plan and fund
set-up
Payer Gateway data translator
(eligibility/benefit verification –
ANSI 270/271) edits connectivity
Payer Gateway data translator
(ANSI 835), ANSI edits connectivity
Payer banking interface
Provider bank
Funds transfer
Financial debtBanking institution EFT transaction
creation and routing
Plan Sponsor Gateway –
data translator (ANSI 834), ANSI edits connectivity
Plan Sponsor Gateway –
data translator (ANSI 834), ANSI edits connectivity
Plan Sponsor Fund
Funds transfer
Payer Gateway data translator
(eligibility/benefit verification –
ANSI 270/271) edits connectivity
Provider office POS (card swipe) device
POS Technology
ERA = Electronic Remittance Advice
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Summary
• ProxyMed is the nation’s ONLY full suite of healthcare business solutions, offering beginning-to-end solutions.
• Transform the remittance advice and payment process from paper-based to electronic, resulting in:
– Automated healthcare claims payment and settlement processes– Improved efficiency– Reduced costs
• Verify eligibility and benefit information prior to administering healthcare services, resulting in:
– Improved administrative overhead– Better cash management– Expedited payment
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ProxyMed Can Help You Achieve Success By…
• Enabling you to focus on core competencies
• Functioning as your single source for all administrative transactions
• Increasing productivity by reallocating resources
• Expediting payment process
• Maximizing profits through increased efficiencies
• Enabling you to focus on core competencies
www.proxymed.com