What HIPAA Covered Entities Can Learn From Property & Casualty eBilling’s End-to-End Revenue Cycle Workflow!

Sherry Wilson, Jopari Solutions, Inc.Tina Greene, Mitchell InternationalTammy Banks, Optum

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Topics

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HIPAA Covered vs Non-Covered Entities - Comparison

• P&C includes workers’ compensation and auto – Legal system vs. a medical system

• Subject to State vs. Federal Regulations – Non-covered entity–exempt from HIPAA

• Subscriber “Employer” vs. “Patient”

• “Bill” vs. “Claim”– “eBill”: electronic billing, attachment, acknowledgment and payment process for

P&C

• “Compensability Determination” vs. “Eligibility of Benefits”

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HIPAA Covered vs Non-Covered Entities - Comparison

*Again remember legal system vs. medical system*

•Heavy reliance on documentation for determining:– Compensability

– Disability

– Medical necessity plus additional state reporting requirements J1 Doctors’ First Report of Injury J2 Supplemental Medical Report J3 Medical Permanent Impairment Report J4 Medical Legal Report J5 Vocational Report J6 Work Status Report J7 Consultation Report J8 Permanent Disability Report J9 Itemized Statement

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HIPAA Covered vs Non-Covered Entities - Similarities

• P&C providers are the same providers that process government and commercial claims today

• Uses the same HIPAA transactions and code sets that are used for government and or commercial claims processing

• Collaborates with the same national standard setting organizations

• Many states include same operating rules in their regulations to gain administrative simplification

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Moving Toward One Automated End-to-End Workflow

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Objectives of eBill Initiatives

• Leverage existing solutions already in use today by covered entities

– same technology platforms– same connectivity

– same process workflows

– same transactions and code sets

• Establish standard end-to-end workflow business rules

• Automate and streamline the standard end-to-end workflow process

• Eliminate unnecessary process steps and paper

• Realize ROI

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Objective of eBill Initiatives

Alignment with current standards•International Association of Industrial Accidents, Boards and Commissions (IAIABC)

– Align states with national standards vs. 50 state proprietary HIPAA regulations

– IAIABC Model Rule (endorsed by AMA)

– IAIABC National Workers’ Compensation Electronic Medical Billing and Payment Companion Guides (X12 collaboration)

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Objective of eBill Initiatives

Alignment with current standards

•Industry collaboration with national standard organizations, including ASC X12, CAQH CORE, IAIABC, NCPDP, NUBC, NUCC, HL7 and others

– Address unique business requirements

– Incorporate use of the HIPAA transaction and code sets

– Advocate for consistent requirements across states

– Collaborate with professional associations, such as AHA, AMA, Cooperative Exchange, WEDI and others

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Automated End-to-End Workflow for All Lines of Business

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Realize Maximum ROI by Solving the Top 10 Business Needs1. State Reform-reduce cost/increase data integrity

2. Automate claim and attachment processing

3. Increase “clean claim” first time submission rates

4. Apply upfront business validation edits

5. Audit trail at every touch point

6. Reduce manual payer payment status inquires

7. Proactively identify claim types to increase processing efficiencies 

8. Decrease accounts receivable days (A/R)

9. Shorten the revenue cycle management time to payment

10. Align, as appropriate, with national standards (operating rules/EFT)

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Solving Those Business Needs

• Address business needs in isolation, does not bring ROI

– Mandating one EDI transaction does not resolve

the complete business issue • Each business need is related to another – only an “end-to-

end” solution that addresses all/majority of business needs will result in maximum ROI

– If solve for one need, another business need negates ROI

• All stakeholder perspectives and buy in are required to ensure adoption

• Without an end-to-end workflow solution there is no ROI

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Solving Those Business Needs

Business Need (example): •Virtually all claims require mailing and faxing of supporting documentation/attachments•Cost to send/receive, handle and match paper documentation is unsustainable

What would be your solution?

Would it be to implement the ASC X12 275 Standard Transaction?

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Solving Those Business Needs

Those of you who said yes…so did the P&C industry…

BUT…does it address:

•Reduce payer chasing/provider calls– Ensure claim and supporting documentation is received by payer– Confirm what supporting documentation is needed

•Address unsolicited attachments•Address incomplete/missing supporting documentation•Address rework on a claim without required supporting documentation

AND SO ON…

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P&C Industry started with the basics:Alignment and adoption of the HIPAA Standard Transactions •Automate Claims

– ASCX12 N v5010 837 Health Care Claim: (Professional, Institutional and Dental) – NCPDP Telecommunication Standard Implementation Guide D.0– NCPDP Batch Standard Implementation Guide 1.2

•Automate Electronic Remittance Advices– ASCX12/005010X221A1 Health Care Claim Payment Advice (835)

Alignment and adoption of the HIPAA Code Sets, including– ICD-9-CM, AMA CPT, Standardized Reason and Remark Codes (CARCs &

RARCs)– Require payers to move from proprietary reason and remarks to national reason

and remark code set

Alignment with HIPAA Privacy & Security Regulations

Alignment with CAQH CORE Operating Rules (ERA/EFT)

Same foundation mandated by HIPAA for commercial and government

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Layered on….

Attachment and Acknowledgment Transactions

Not currently mandated under HIPAA, but found to be critical to solving for business needs and ROI

•Adopted Attachment Solution – ASC X12N/005010X210 Additional Information to Support Health Care Claim

(275)– Other existing flexible technology solutions– Flexible formats-existing solutions-clinical information

Over one million attachments being processed a month

Jopari Solutions, Inc.

•Adopted Acknowledgment Solutions– ASCX12/005010 TA1 Acknowledgment– ASC X12C/005010X231A1 Implementation Acknowledgment (997/999)– ASCX12N/005010X214 Health Care Claim Acknowledgment (277CA) 

Transactions that go into the back hole, without acknowledgments, result cost

timely intensive phone calls for payers and providers.

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Front-End Edits

•“Complete Bill” (clean claim) requirements– Syntactically edits same as commercial and governmental edits– State specific eBill regulation edits– National P&C business requirement edits– Attachment front-edit rules - Attachments requirements for specific

procedure/services billed (unsolicited)

Handling a claim and supporting documentation once –

brings true ROI for payers and providers!

Layering on….

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Additional Transaction Edits and Process Rules

Established Duplicate Claim, Appeal and Reconsideration Rules •NUBC Workers Compensation Condition Codes

– Duplicate Claim Condition Code = W2– Appeal/Reconsideration Condition Codes = W3, W4

Adoption of related CAQH CORE Operating RulesStandardized Reasons and Remark Codes•Adoption of ASCX12 Technical Type Report 2 (TR2)•Defines national Workers’ Compensation CARC/RARC Usage Rules

• Require payers to move from proprietary reason and remarks to national reason and remark code sets

•Adoption of business scenario definitions in addition to P&C specific scenarios to provide standardization of payer code usage •Enables backend revenue cycle workflow automation

Layered on….

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Recognize variation in EDI Readiness - Low Tech to High Tech

Claims Submission Solution•Direct data entry to batch processing

Attachment Solution - Allow flexibility for….•Submission Methods: Sending attachments via secure electronic fax, secure encrypted email or other secure electronic transmission using the prescribed format (275) or a mutually agreed upon format. •Format Content: Allow flexible formats based on Trading Partner Agreements (e.g., PDFs, TIFFs, C-CDA, Objects) to accommodate PMS, EMR and/or other administrative/clinical systems.•Vendor Attachment Solutions – Low Tech to High Tech

– Bar coded coversheets and automated, secure Fax servers – Web Portal upload of single or batches PDF or TIF images,– EDI using ASCX12N 275 attachment standard transaction– EDI using other methods

Layered on…

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Solving Business Needs

Adoption & Education•IAIABC Model Rule template created a national standard approach•Some states enacted eBill regulations included or based on IAIABC Model Rule template•Payers implemented:

– Individual state mandates – Voluntarily applied eBill across all states where conduct business regardless if

mandate in place – Made good business sense - drove ROI

•Vendors implemented in existing solutions – Marketed existing solution for workers’ compensation and auto eBilling– Made good business sense-one workflow solution all lines of business

•Providers have more incentive to engage when solutions are incorporated within their existing workflow – clear ROI

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P&C End-to-End Workflow ROI -5 Year Study

 

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Example of State Estimated ROI

 State Metrics 

ROI Estimated Results 

Comments

Example State Reform: California

“Hard administrative calculated savings $600 million year”

Payer state reporting mandateseBill Effective Date: 2012Audit penalty timelinesAcknowledgments - Electronic Audit Trail

Example State Reform: Texas

Reduce paper intense process up to 60% Expects similar savings as California

Payer state reporting mandateseBill Effective Date: 2009Audit penalty timelinesAcknowledgments - Electronic Audit Trail

WC Reform Top Priority for States

Group Health/CMS/other eBill State EDI ROI calculated savings - cost drivers for reform

Increase state momentum over the past 3 years

State eBill Reported Benefits as of June 2013 (actual ROI TBD) Improved integrity and accuracy of data collected by the state Critical to medical cost containment analysis Data integrity has had significant impact on the state efforts to contain medical costs, which

constitutes 60% of claims cost nationwide eBill regulations supports quality/best practice analysis states are undertaking

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Provider Reported ROIMetrics(Paper vs. eBill)1

National Occ. Health Service 2

CA based OrthoPractice

CA based Billing Service

CA based Small Practice

First Time Acceptance

70% to 90% 50% to 83% 68% to 88% 40% to 84%

Resubmission Rate

20% to 3% 40% to 8% 25% to 5% 50% to15%

Revenue Cycle Improvements

DAR 80 to 45% Over 120: 35 to 6

DAR 93 to 42% Over 120: 53 to 15

DAR 73 to 38% Over 120: 57 to 22

DAR 75 to 39% Over 120: 62 to 24

Payment Cycle 45 to 19 days 63 to 27 days 58 to 31 days 67 to 28 days

Reduction Payer Status Calls

83% 58% 39% 53%

Notes:1. These are survey sample results from several practices that have been engaged in eBilling for 1 to 5 + years submitting to varies numbers on payers.2. Source: Jopari Solutions, Inc., Property & Casualty Electronic Medical Bill (eBill) White Paper - 5 Year Industry Progress Report, published June 25, 2013.

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Average Payer Reported ROI Metrics(paper vs. eBill)  

Average Payer ROI Reported Results

Reported Drivers

Clean Claims First Time Submission Rates

63% increase Complete Clean Claim RulesFront-End EditsAttachments sent with Claim Acknowledgments

Duplicate Claims Submission

70% reduction Front-End EditsWC NUBC Condition Codes = W2Acknowledgments

Appeal/Reconsiderations 45% reduction Front-End EditsAcknowledgments Standard ERA FormatCARC/RARC Codes/Proprietary

Payment Status Inquires 64% reduction Front-End EditsAcknowledgments Standard ERA FormatCARC RARC Codes/ProprietaryASCX12 TR2 WC CARC/RARC Usage Rules

Payment/Remittance Cycle 60 -100 days to14 Days Automated End-to-End Business WorkflowFront-End EditsAcknowledgments

Overall Reduction 70% reduction Automation End-to-End Business WorkflowTriage Time Sensitive Claims & Document Processing

18 to 35 days to less than 2 days* Mitigates Audit Penalties

NUBC Condition Code EditsAttachment Edit RulesAcknowledgments - Audit Trail - Triage

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Regional Healthcare Provider ROI

• 6 sites in San Diego County

• 17 Physicians, 6 Physician Assistants = 18.4 FTEs

• 110,000 Patient Visits per year

• 43% Workers’ Compensation – 47,744 visits– 13,262 cases

• 31% Pre-Employment Services – 33,973 visits– 4,000 active employers

• 26% Commercial – 28,283 visits

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Cost Savings

Due to Less:Phone CallsFaxingChart PullsMailingsManual Billing

Decreased FTE Allocations:Patient Service Rep – 2.12 FTE’s

Medical Assistant – 2.35 FTE’sHIM – 3.17 FTE’s

Specialty Care Case Mgmt. – 1.08 FTE’s

Billing Rep – 3.88 FTE’s

Authorization Rep – 2.00 FTE’s

Total Reduction = 14.60 FTE’s

FTE Salary and Benefits Saving: $760,705 per yearFTE Salary and Benefits Saving: $760,705 per year Workflow Automation Cost Savings: $276,142 per yearWorkflow Automation Cost Savings: $276,142 per year Net Cost Savings: $484,563 per yearNet Cost Savings: $484,563 per year

* Other expenses (paper, stamps, envelopes, etc.) – not included* Other expenses (paper, stamps, envelopes, etc.) – not included

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2010 2011 2012 2013 2014

Visits (Occ. Health) 80,406 84,193 87,887 101,965 110,000

Reduction in FTE’s 6.71 1.97 2.00 2.00 1.89

Days in AR 68 62 54 50 46

Collection Rate 84% 85% 86% 86% 91%

Outcomes

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Compliance Landscape - 2009

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Regulatory Compliance Landscape 2014

Legislation ActivityPending No ActivityEFT Required

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Today eBill Processing inAll 50 States

Voluntary adoption due to ROI - not state mandates

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• EDI adoption has been an evolution

– Healthcare 18 + years

– WC less than seven years

• Share many of the same stakeholders

• Share the same costs, issues & needs for ROI

• Share a same common administration simplification goal– One automated workflow across all lines of healthcare business

– Opportunity to leverage existing IT investments to achieve this goal

One Workflow for All Lines of Healthcare Business

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• National Market place demand already exists

• EDI Highway already built

• Industry connectivity resources already engaged in P&C claims and attachment processing

• Vendors implemented in existing solutions

• Providers and payers can use same automated workflow they use today for commercial & government claim processing

• Ability to leverage your existing IT investment to expand your business applications to include P&C

One Workflow for All Lines of Healthcare Business

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We need your help with stakeholder engagement!•To achieve increased stakeholder engagement, as an Industry we must:

– Collaborate – Educate – Standardized Connectivity– Align with Standards and Operating Rules,

as appropriate

Take action today •Sign up for the WEDI P&C WG

– Networking stakeholders who do P&C business– Many state regulators engaged– Discuss workflow automation challenges, opportunities and identify solutions

using same technology

One Workflow for All Lines of Healthcare Business

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WEDI Property & Casualty

eBill Educational References

White Papers•Property & Casualty eBill Business Requirements and Best Practices White Paper•Property & Casualty Code Value Usage Guidelines for Health Care Payment

White Paper•Property & Casualty National Council for Prescription Drug Programs, (NCPDP)

Business Requirements White Paper

ICD-10 •WEDI Statement to NCVHS on Standards Regarding: ICD-10 Implementation Beyond Covered Entities on February 19, 2014 •WEDI PowerPoint•States aligning with the CMS ICD-10 requirements

Other•Summary eBill State Business Rules and Regulations

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Join today! P&C eBill SWG

Joining a workgroup is easy –

–Sign in at www.wedi.org on the WEDI website –Select My Profile –Subscribe to the listserv that corresponds with each workgroup that you’d

like to join or contact Sam Holvey at 202-618-8803, sholvey@wedi.org

Share with your connectivity partners!

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Questions