Real Time Claim Adjudication Clearinghouse Perspective by aqu16527

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									       Real Time Claim Adjudication
        Clearinghouse Perspective
                        Mary Rita Hyland AVP
                         The SSI Group, Inc.
                            HIMSS 2008

                          The Past
• Fifteen years ago, many hospitals and clinics were just beginning
  to communicate electronically with payers, replacing paper
  claims with electronic versions submitted in more than 400
  proprietary formats over private networks.
• Today, most claims are submitted electronically in the standard
  HIPAA-mandated format via the internet. And provider-payer
  electronic communication finally is expanding to include other
• Some of the fastest growing transactions are eligibility
  verification, remittance advice and funds transfers.

       Electronic Claims Processing
• Since the very beginning of electronic claims processing, it's
  been common for a claim to go through several middlemen
  before reaching its destination at an insurance company. For
  several years,
• Aetna Inc., for example, required that all its claims had to be
  funneled through the clearinghouse of Emdeon Business
  Services, Nashville, Tenn. As a result, a clinic that served Aetna
  customers but used a regional clearinghouse might see its
  claims go from that clearinghouse to Emdeon before reaching

                Direct Submissions
• In recent months, Aetna has announced it's accepting claims
  directly from several other clearinghouses, including The SSI
  Group, Inc.
• Responding to demand from providers, the payer decided to
  offer them more flexibility in choosing which clearinghouses to
  use to submit electronic transactions, a company spokesman
• The Aetna action is a new trend. Payers want to work with
  vendors/clearinghouses that contract with the physicians to be
  able to exchange data directly with the physician.

                  Direct Connection
• Payers want to be able to send clinical data to physicians.
• Direct connections reflects a long-term goal of exchanging
  clinical data for disease management.
• Proactive treatment and monitoring of disease conditions will be
  one of the advantages seen by these efforts in conjunction with
  moving toward electronic health records (EHR’s and PHR’s).

• Real time adjudication will tell doctors within seconds of receiving
  the claim how much they will be paid and the amount the patient
  should be billed.

                 Payer Adjudication
• As payers begin to dabble in real-time adjudication of claims,
  they're taking widely varying approaches.
• For example, Blue Cross and Blue Shield of North Carolina is
  focusing primarily on claims adjudication after the patient is
  treated at a doctor's office. In contrast, BlueCross BlueShield of
  Tennessee is providing a real-time service that estimates
  patients' self-pay balances before treatment.

                 Payer Adjudication
• The North Carolina plan originally had promoted real-time
  adjudication at the time of service, but physicians said that didn't
  fit their workflow. The Blues plan as a result shifted its strategy to
  provide real-time services on the back-end, when billers for a
  group practice are preparing a claim.

      Payer Portal vs. Clearinghouse
• Iredell Memorial Hospital obtains electronic remittance advice
  from several major payers through its clearinghouse, The SSI
  Group Inc., Mobile, Ala. The Statesville, N.C.-based hospital
  experimented with using payer Web sites for various
  transactions, but stopped because it was far easier to use one
  clearinghouse to reach all payers, says Keith Williams, director of
  patient financial services.

               Claims Submissions
• Providers are better served by using a single clearinghouse to
  send their claims to dozens of payers, rather than struggling to
  use the portals of each payer individually.
• Web portals have not caught on because payers and providers
  alike are better served by having a clearinghouse in the middle to
  edit claims to make sure they're complete and accurate. Over the
  past 20 years, SSI has developed over 250,000 edits which can
  be payer, provider, or regulatory in nature.

              Clearinghouse Future
• To remain viable, today's clearinghouses are diversifying to offer
  a full range of revenue cycle management services as well as a
  wider variety of clinical and financial transactions.
• Clearinghouses are moving towards Real Time Adjudication by
  partnering with payers. Payers like Aetna, Blue Cross and Blue
  Shield, United Healthcare are building relationships with more
  clearinghouses that can handle real-time transactions, such as
  verifying patient self-pay balances, because of the growth of
  consumer-driven health plans.

                  Mary Rita Hyland
              Assistant Vice President
                  Regulatory Affairs
                 The SSI Group, Inc.
              1-800-880-3032 ext 1120

      CareCalc and Real Time
The Future is……. Claims
          Brief Status Summary
      …………………..Real Time

Barney Dreistadt,
September, 2007
Director, Provider Service Design/Build
February, 2008

                  Focus of this Presentation

      • Affordability
           – Eliminate unnecessary administrative cost

      • Transparency
           – Informed consumer choice


       • Increasing:
          – Number of uninsured
          – Deductibles and cost sharing
          – Use of technology
          – Demand for health care

       • Decreasing
          – Tolerance for error and delay
          – Willingness to wait for answers

                              Transaction Environment

                • Heretofore mostly batch
                • Time between submission and response
                • Error prone
                • Costly rework
                • Confused patients/members
                • Confused providers
                • Harried payers

Draft “Backbone” of Electronic Interchange between Payer an Provider

  Eligibility                 Author-
                                            Claim                             Corrections
     And                      izations               Explanation   Receive
                    Claim                   Status                                and
  Benefits                      and                  of Payment    Payment
                                           Inquiry                            Adjustments
   Inquiry                    Referrals

Practice Management/Hospital Management Systems                                                  Transaction
  270 271 837P                 278 276 277                  835                                  Accepted by
          837I                                                                                   Both Parties

                              Author-                              Generate
 Eligibility                                                                  Corrections
             Adjudication     izations     Status    Explanation   Payment
And Benefits                                                                      and
                                and       of Claim   of Payment    (Check/
Information                                                                   Adjustments
                              Referrals                              EFT)


Make basic standardized electronic transactions easy to use, fast and accurate

                                            Key elements
                •       Increase real time transactions
                •       Prepare providers and patients/members with
                •       Increase self service
                •       Reduce rework, calls, and costs
                •       Leverage technology

  Past                Today                      It’s a Journey                                         Future
      Lo-Tech                                                                                 Hi-Tech
    • Paper and staples                                                              • Fully automated
    • Batch                                                                          • Real Time
    • Limited tools                                                                  • Integrated with PMS


• Consumer Involvement
   – Supports transparency of information
   – Earlier in the patient service cycle
   – Reduced consumer confusion
• Administration for new types of health plans
   – How benefits are applied
   – Collection of patient responsibility
• Lower cost of operation
   – Self-service; reduced need for phone calls


• Reduced consumer confusion
   – Clear patient responsibility amount
   – Fewer refunds/additional charges

• Makes administration of new types of health plans
   – High deductibles/coinsurance
   – Accounts (FSAs;HRAs; HSAs)

• Supports transparency of information for


• Improved A/R for providers
   – Consumer payments
   – Provider payments
• Lower cost of operation
   – Provider office
      • Increased self-service/less time on phone calls
      • Less rework/refunds/need for explanations of
        additional member responsibility
   – Insurer
      • Fewer provider calls; less rework
      • Fewer phone calls from members

 How?                           Even basic real time transactions can help at several
                                points to reduce patient confusion and improve cash flow

Provider Office Flow
                              2) Office             3) Patient                        4) Schedule                   5) Patient may be
  1) Patient calls
                             schedules            inquires about                      preparation/                 notified of estimated
 for appointment
                               patient             amount owed                   insurance verification               amount to pay
          ilit         ate                ate               ate                          y                ate                   ate
       gib         tim              tim               tim                           ilit            tim                   tim
 Eli            Es             Es                Es                              gib           Es                    Es

Date of service
                                                                                                                       Real Time
                                7) Patient is                 8) Patient check-
                                                                                                  9) Patient           improves
 6) Patient arrives            treated / seen                 out/ collection of
                                                                                                   leaves             collection of
                                by physician                    amount owed
                                                                                     e                                  patient
               y                                                                 Tim
          ilit         ate                                                    al                                     responsibility
       gib         tim                                                      Re laim
 Eli            Es                                                             C

Post-service                                    Real Time transactions help reduce
          10) Payment                            reconciliation, refund checks and
          reconciliation                            other work at the back end.

                  Potential Approach – All Real Time

  Eligibility                 Estimator                      Real Time Administrative                                Clinical
                                                              Claim     Integration                                Integration
        & Benefits            Real time patient             Submission       Practice                                 Electronic
            Magnetic          responsibility                                                     Management           Health
           Stripe Card        estimates               While patient is                             System             Records
            Initiated          – Fast, accurate       still present                                                       Ordering:
           Eligibility &                                                                      Financing                   Ancillaries
                              detailed             With real time                            mechanisms:
            Benefits                               response                                                               Pharmacy
                              response                                                                                    Referring
             Inquiry                                                                         Debit;Credit;
                                                Final, accurate
                                                collections                                  HSA/HRA/FSA            Unlimited

 How?                           Even basic real time transactions can help at several
                                points to reduce patient confusion and improve cash flow
Provider Office Flow
                              2) Office             3) Patient                    4) Schedule                       5) Patient may be
  1) Patient calls
                             schedules            inquires about                  preparation/                     notified of estimated
 for appointment
                               patient             amount owed               insurance verification                   amount to pay

Date of service
                                7) Patient is                       8) Orders,                8) Patient check-
                                                                                                                       9) Patient
 6) Patient arrives            treated / seen                     authorizations,             out/ collection of
                                by physician                         referrals                  amount owed

   10) Payment
                              11) Patient
                                                                  Imagine the Possibilities

                   What are the impediments?
  • Utility
            – Many offices have become accustomed to services being covered
              with small co-pays
            – Have not yet “felt” the future

  • Fit with office flow
            – Batch orientation
            – “We’ve always done it this way”

  • Complexity/Compatibility with current systems
            –      Many to many to many relationships
            –      Practice Management Systems:portals:insurers
            –      Inherent complexity of many claims
            –      Complex work environments

  • Lack of attractive alternatives


                                          Real Time Claim Estimator

                                                          What is CareCalc?

              • A tool to calculate how much a patient owes
                        -       Can be used prior to or at time of service
                        -       Works through Availity®1Eligibility and Benefits screen
              • Goes through the same steps as a claim
                        -       Specific contractual allowances
                        -       Specific member benefits
                        -       Deductible and benefit maximum accumulators
                        -       Claims edits
              • Responses are provided real-time, based on information
                at the time of the inquiry
1 Availity, L.L.C., is an independent company formed as a joint venture between Navigy, Inc., a wholly owned subsidiary of Blue Cross and Blue Shield of Florida, Inc., Health Care Service

Corporation, and HUM-e-FL, Inc., a subsidiary of Humana, Inc. Blue Cross and Blue Shield of Florida has business arrangements with Availity with the goal of reducing costs in the Florida
health care marketplace, simplifying provider workflow, improving patient experience and in providing HIPAA-AS compliant solutions. For more information or to register, visit Availity’s website

                            Provider Value
CareCalc enables our providers to know what to collect with high accuracy
prior to or at the time of service. Based on the early returns of a recent
survey providers report that use of this capability reduces administrative
costs and improves collection:
     – Decreased claim denials
     – Decreased refund checks
     – Reduction in time for patient check in/check out
     – It is easier for providers to explain to patients how their insurance
       benefits are applied

            86.5% Satisfied or Very Satisfied with CareCalc
   “We reduce time spent on the              “We are saving on collection
     phone (with BCBSF) for                   costs as more patients are
     patient’s responsibility.”              paying at the time of service.”
          OB GYN Practice                              Imaging Center
            Tampa, FL                                     South FL


     • Much can be gained

     • Key stakeholders want real time transactions

     • We have the technology

     • Some impediments must be overcome

     • Some of us are trying

     • How can we reach a beneficial industry wide tipping


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