Business Analysis Of

Business Analysis Of

BUSINESS ANALYSIS OF

ELECTRONIC BILLING VOLUME FLOW OBSTACLES

Presented to SeBin Education Workgroup

June 6, 2008

By: Cheryl Glotzer

Coventry Worker’s Compensation

SeBin Ebill Group Co-Chair

OBSTACLES TO VOLUME FLOW FOR ELECTRONIC BILLING

Electronic billing in Texas has been implemented since 1/1/08, yet the industry has not yet seen bill volumes reach the anticipated levels. What are the factors that are constricting the flow of electronic bills?

ISSUE ANALYSIS

There are several factors that have contributed to the overall constriction of electronic bill volume:

  1. Connectivity – One of the basic building blocks of an industry-wide electronic billing system is the ability of providers and payors to connect to each other electronically. Providers and payors may use various methods to obtain this connectivity:
  2. Direct connections with each other allowing transmissions of 837, 275 and 835 data between them with no middleman.
  3. Connectivity through their current Clearinghouse and then to the payor.
  4. Connectivity through an Ebill Agent and then to the payor.
  5. Connectivity through their Clearinghouse to an Ebill Agent to the payor’s Clearinghouse and or Ebill Agent.
  6. Any combination of b-d above.

This level of connectivity must be available through the use of Trading Partner Agreements between all participating Clearinghouses and Ebill Agents. Currently, these agreements are in place with only approximately 25%(?) of the Clearinghouses and Ebill Agents.

  1. Payor IDs – Another building block is the ability of the provider to electronically identify the payor that bills are being submitted to, and determine what electronic location the bills must be sent to. As things stand today, payors, Ebill Agents and Clearinghouses all have assigned some sort of identification tag to their payors. Unfortunately, these identification tags, or payor ids, are not universally recognized by every other Ebill Agent and Clearinghouse. Without this universal recognition, bills cannot move electronically from point to point. To further complicate matters, in the WC industry:
  2. It is possible for the same payor to have books of business with several different bill review companies, each of whom may have relationships with different Ebill Agents or Clearinghouses.
  3. It is possible for the same claimant to have more than one active claim that is handled by different payors.
  1. Attachments –Attachments are documents submitted with medical bills that are deemed necessary (by state requirement, payor requirement or in the provider’s judgment) to support the charges submitted for reimbursement. There are tw6 types of attachments:
  2. Solicited – required by state or payor requirement.
  3. Unsolicited – sent by the provider without regulatory or payor request or requirement.

Approximately.90% of all WC bills are submitted with attachments and Texas has mandated the submission of specific attachments as part of it’s electronic billing requirements. It is necessary that the provider’s and payor’s Clearinghouse or Ebill Agent has the technology to accept attachments from various sources (electronic 275, electronic images, faxes, email and paper), convert them to the ANSI 275 format, associate them to the bill (837) that they support and have inbound/outbound transmission capability.

ALTERNATIVES

  1. Connectivity
  2. Providers and Payors may establish direct EDI connectivity with each other. This approach requires both parties to establish and maintain multiple EDI connections and associated inbound/outbound file mappings.
  3. Providers and Payors may elect select an eBill Agent or Clearinghouse as the inbound/outbound gateway for all electronic billing traffic. The Provider or Payor would select the eBill Agent or Clearinghouse that has established or is in the process of establishingthe greatest number of Trading Partner Agreements with other eBill Agents and Clearinghouses.
  4. Providers and Payors may elect to establish a combination of the two options.
  5. Payor ID
  6. Providers, Payors, eBill Agents and Clearinghouses may assign their own unique identification code using any combination of alphanumeric characters. This method does not assure the recognition of said identification code by others in the industry and may as a result, inhibit electronic billing data flow.
  7. The states implementing electronic billing may elect to assign specific identification numbers to payors, providers, eBill Agents and Clearinghouses that participate in the state’s electronic billing process. This would assure electronic billing dataflow, but would require the state to maintain the list of identification numbers and could result in identification numbers that vary by state. This would create the need for crosswalk tables for the various state identifiers.
  8. The industry could elect to use an identification number that is already in use within the industry and follows a specific format. One example might be the 5 digit NAIC number. The listing of these numbers could be maintained by an industry recognized objective organization such as the IAIABC. Payors and Providers to could apply to the organization for a new Payor ID or register their existing identifier. The maintaining organization would then publish a list of the identifiers that was easily accessible to all users.
  9. Attachments
  10. Providers may elect to send both solicited and unsolicited attachments for electronic bills directly to payors via email, fax or paper. The drawbacks to this approach include:
  11. Overloading payor email servers, fax machines/servers, mailroom personnel.and filing systems.
  12. Payors may not be able to match attachments to the electronic bills they support.
  13. Attachments may be lost during processing resulting numerous resubmission requests from payors.
  14. Providers may use an eBill Agent to screen out unsolicited attachments, enforce required attachments, convert their attachments to ANSI 275 format and marry them to the electronic bills (837) data they support. Payors may use an eBill Agent to accept the inbound electronic bills and associated solicited attachments, marry them together and convert them to data and image formats that can be loaded into their claims systems.
  15. Clearinghouses may partner with eBill Agents to act as a gateway for their providers and payors.
  16. Providers - Converting electronic data from Practice Management Systems to ANSI 837 format, converting attachments received via paper, fax and email to ANSI 275 format, marrying the items together and forwarding them to the Clearinghouse for delivery.
  17. Payers – Converting ANSI 837/275 data and images to formats that can be loaded into their claims systems.

RECOMMENDATIONS

Connectivity - Providers and Payors should utilize a single eBill Agent or Clearinghouse as the inbound/outbound gateway for all electronic billing traffic. The Provider or Payor would select the eBill Agent or Clearinghouse that has established or is in the process of establishing the greatest number of Trading Partner Agreements with other eBill Agents and Clearinghouses. Clearinghouses and eBill Agents should partner with each other to ensure the swift, successful free flow of data for their provider and payor clients.

Payor ID -The industry should elect to use an identification number that is already in use within the industry and follows a specific format. One example might be the 5 digit NAIC number. The listing of these numbers could be maintained by an industry recognized objective organization such as the IAIABC. Payors and Providers to could apply to the organization for a new Payor ID or register their existing identifier. The maintaining organization would then publish a list of the identifiers that was easily accessible to all users.

Attachments - Providers should use an eBill Agent to screen out unsolicited attachments, enforce required attachments, convert their attachments to ANSI 275 format and marry them to the electronic bills (837) data they support.

Payors should use an eBill Agent to accept the inbound electronic bills and associated solicited attachments, marry them together and convert them to data and image formats that can be loaded into their claims systems.

Clearinghouses should partner with eBill Agents to act as a gateway for their providers and payors.

  • Providers - Converting electronic data from Practice Management Systems to ANSI 837 format, converting attachments received via paper, fax and email to ANSI 275 format, marrying the items together and forwarding them to the Clearinghouse for delivery.
  • Payers – Converting ANSI 837/275 data and images to formats that can be loaded into their claims systems.

ELECTRONIC BILLING AND ATTACHMENT PROCESSINGPage 1 of 10

Exhibit I

ELECTRONIC BILLING AND ATTACHMENT PROCESSINGPage 1 of 10

Exhibit II

GLOSSARY OF TERMS

Acknowledgement – Electronic response that receiver sends to the submitter as part of the electronic billing process, to signal that a transaction has been received. The response may be positive or negative. WC electronic billing supports TA1 (optional), 997 (file level) and 824 (detail level) ANSI X12 acknowledgement transactions.

ANSI (American National Standards Institute) - A private, non-profit organization that administers and coordinates the U.S. voluntary standardization and conformity assessment system..

ANSI X12 275 Transaction – ANSI standard format for transmitting supporting documentation for 837 data electronically.

ANSI X12 271/272 Transaction – ANSI standard format for provider to request electronic eligibility status (271) and payer to respond (272).

ANSI X12 276/277 Transaction – ANSI standard format for provider to electronically request status of the processing of a bill (276) and the provider to respond (277).

ANSI X12 837 Transaction – ANSI standard format for transmitting bill data electronically.

ANSI X12 835 Transaction – ANSI standard format for transmitting adjudication outcome (EOR) data electronically.

Attachment – Documentation submitted by the provider as required by the WC jurisdiction or, in support of the billed services provided to the claimant. This information is an optional part of electronic billing, but the majority of WC bills are submitted with attachments.

Bill – The standardized document used by WC providers to seek payment from WC payers for services rendered. In Group Health a bill is called a claim. In the electronic billing process, these are converted to ANSI 837 (or mutually agreed upon) format.

Claim – The alphanumeric identifier attached to a specific WC injury incident, for a specific claimant. Once this identifier is setup by the payer, all subsequent bills should reference it.

Clearinghouse – A vendor that receives, translates and delivers large volumes of bills as part of the billing process between providers and payers. In the WC electronic billing world, the bills may come from another clearinghouse or ebill agent, or the provider’s practice management system. The larger clearinghouses specialize in Group Health and may or may not offer the specialized attachment processing required for WC. This vendor may act as an agent for the provider, payer or both in the electronic billing process.

Ebill Agent – In the WC electronic billing world, a vendor that receives, translates and delivers bills and attachments as part of the billing process between providers and payers. In the WC electronic billing world, the bills may come from another clearinghouse or ebill agent, or the provider’s practice management system. Ebill agents should offer the specialized attachment processing needed to process the majority of WC bills. This vendor may act as an agent for the provider, payer or both in the electronic billing process.

WC Electronic Billing – The process by which a provider submits WC bills and related attachments to payers for processing and payment. The process includes:

Base Requirements

  • accepting bills and attachments from providers via mail, email and fax
  • converting submitted bills to 837 or (mutually agreed upon) format
  • validating submitted bills based on jurisdictional Clean Claim Guidelines.
  • delivering the converted 837 data to payers for review and payment.
  • delivering the adjudication outcome from the payer to the provider in ANSI 835 (or mutually agreed upon) format

Optional Functionality

  • receipt and delivery of eligibility inquiries in ANSI 271/272 (or agreed upon) format between providers and payers.
  • receipt and delivery of bill status inquiries in ANSI 276/277 (or agreed upon) format between providers and payers.

Specialized Attachment Handling

  • accepting attachments from providers via mail, email and fax
  • converting attachments to 275 (or mutually agreed upon) format
  • reading the PWK segment of submitted 837s (bills converted to ANSI 837 (or mutually agreed upon) format for attachment indicators
  • pending received bills until attachment has been submitted (based on state guidelines)
  • matching pended bills to attachments that are received
  • rejecting bills for which attachments are not received within the specified timeframe (based on state guidelines)
  • providing acknowledgement to providers of the receipt of bills and/or attachments
  • delivering linked bill (837) and attachments (275) from provider to payer.

Payer – Carrier, TPA, Self-Insured entity that issues payments to providers for WC services.

Provider – Entity (Physician, Hospital, Pharmacy, Facility…etc) that submits bills to payers for payment of services rendered to claimants for WC related injuries.

Standalone Payer – Carrier, TPA or Self-Insured that requires providers to setup a direct EDI connection with them in order to send bills to them electronically. Bills are not accepted from clearinghouses or ebill agents. The payer may charge the provider for processing bills.

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