Go Paperless and Get Paid: Use of the EFT/ERA Transactions with X12 and OhioHealth

Transcription

1 Go Paperless and Get Paid: Use of the EFT/ERA Transactions with X12 and OhioHealth November 14, :00 3:00 PM ET 2018 CAQH, All Rights Reserved.

2 Logistics Presentation Slides and How to Participate in Today s Session You can download the presentation slides at after the webinar. Click on the listing for today s event, then scroll to the bottom to find the Resources section for a PDF version of the presentation slides. Also, a copy of the slides and the webinar recording will be ed to all attendees and registrants in the next 1-2 business days. Questions can be submitted at any time using the Questions panel on the GoToWebinar dashboard CAQH, All Rights Reserved. 2

3 Session Outline Requirements for Exchanging EFT & ERA Transactions; WEDI & Other Resources Operationalizing the Phase III CAQH CORE EFT & ERA Operating Rules OhioHealth Implementer Experience Q&A 2018 CAQH, All Rights Reserved. 3

4 Acknowledgments CAQH CORE thanks the guest presenters for today s webinar. Pamela Grosze Vice President and Senior Product Manager, PNC Bank Healthcare WEDI Board of Directors & Remittance Advice & Payments Co-Chair ASC X12N 835 Co-Chair Randy Gabel Senior Director Revenue Cycle OhioHealth Stephanie Glass Director Revenue Cycle, Corporate Cash Posting OhioHealth 2018 CAQH, All Rights Reserved. 4

5 Remittance Advice and Payments How can we do these electronically and what resources can help me? Pam Grosze VP, Senior Product Manager PNC Bank Healthcare November 2018

6 Electronic Funds Transfer and Electronic Remittance Advice A healthcare EFT transaction - electronic message used by health plans to order, instruct or authorize a depository financial institution (DFI) to electronically transfer funds through the Automated Clearinghouse (ACH) network from one account to another. ACH network the secure electronic network for the direct transfer of funds and data from one DFI account to another. Electronic Remittance Advice - adjudication information about healthcare claims from the health plan. Payments Denials Adjustments Patient Liability 6

7 Impact of the Affordable Care Act EFT mandated effective January 1, Health Plans must support EFT. EFT Standards Final Rule makes EFT a HIPAA transaction. oif a provider asks for it the payer must be able to send it. oeft Standards Final Rule makes EFT a HIPAA transaction. Format is NACHA CCD Plus Addenda. oaddenda must be populated with the TRN Reassociation Trace Number segment as defined in the ASC X12N 835 version 5010 TR3 (Implementation Guide). Healthcare Claim Payment/Advice (835) mandated as part of original HIPAA legislation. Format is ASC X12N/005010x CFR

8 Impact of the Affordable Care Act Operating rules support the adopted standards for health care transactions by fostering and enhancing uniform use of the standards across the health care industry. Encourages adoption of electronic transactions. Mandated by the Affordable Care Act effective January 1, Additional Operating Rules are specific to the EFT. 45 CFR

9 EFT and ERA Payment Flow EFT Payer ODFI ACH RDFI 835 Clearinghouse 9

10 NACHA the Electronic Payments Association and the ACH Network NACHA is the private sector rule-making organization that administers the ACH Network. The ACH Network: The secure electronic network for the direct transfer of funds and data from one DFI account to another. Is accessible via more than 13,000 U.S. financial institutions. More than 21.5 billion ACH payments in 2017, moving $46.8 trillion in value. Develops, maintains, and enforces the NACHA Operating Rules. 10

11 NACHA Operating Rules NACHA Operating Rules: Establish the legal foundation for the ACH Network. Provide a common set of rules and formats. Create certainty and interoperability. Prescribe roles and responsibilities. 11

12 NACHA Operating Rules Updates for Healthcare The NACHA Operating Rules and CCD+ Standard have been refined to align with Healthcare Operating Rules, effective 9/20/13. The NACHA Operating Rules require the receiver (provider) to authorize the Health Plan to originate ACH entries to their account, and to enter into an agreement with the Originator (Payer) in which they both agree to be bound to the NACHA Operating Rules. 12

13 NACHA Operating Rules Updates for Healthcare Unique Identification of Healthcare EFTs Healthcare transactions must be clearly identified using the identifier HCCLAIMPMT in the Company Entry Description field. Allows RDFI s to identify healthcare transactions to ensure compliance with healthcare requirements in the NACHA Operating Rules. Addition of New EDI Data Segment Terminator Option to use a tilde (~) in addition to the backslash (/) to indicate the end of a data segment carried in the Addenda record Payment Related Information field. 13

14 NACHA Operating Rules Updates for Healthcare Additional Formatting Requirements for Healthcare EFTs Company Name used in Healthcare transactions must be the name of the health plan that is recognized by the healthcare provider and to which the healthcare provider submits its claims. Name of the Health Plan originating the entry. Name of the Self-Insured Organization s Third-Party Administrator. The transaction must include an addenda record that contains the ASC X12 Version TRN (Reassociation Trace Number) data segment from the corresponding 835 file. Delivery of Payment Related Information (Reassociation Number) The RDFI must provide, either automatically or upon request, all information in the Payment Related Information field of the Addenda Record, no later than the opening of business on the second Banking Day following the Settlement Date. The RDFI must make available an option to receive this via a secure, electronic means. 14

15 Resources Available ASC X12N/005010x221 TR3 (available at White papers available at knowledge center. CAQH CORE Operating Rules available at NACHA Operating Rules available at Administrative Simplification Enforcement and Testing Tool (ASETT) available at Includes links for notification for enforcement of issues for transactions and code sets. Includes tool for testing 835 and other HIPAA standard transactions. 15

16 WEDI Resources Available Documents by the Remittance Advice & Payment SWG Best Practices for EFT Enrollment Security (just published!) Barriers to Adoption of the EFT and ERA Transactions EFT Relationship to the 835 Reassociating Healthcare Payments Overpayment Recovery in 5010 NACHA Operating Rules Updates EFT and ERA Enrollment Process Implementing a Healthcare Payment EFT Process NPI Utilization in Healthcare EFT Transactions 16

17 Operationalizing the Phase III CAQH CORE EFT & ERA Operating Rules Robert Bowman CAQH CORE Director 2018 CAQH, All Rights Reserved. 17

18 CAQH CORE Mission & Vision MISSION Drive the creation and adoption of healthcare operating rules that support standards, accelerate interoperability and align administrative and clinical activities among providers, payers and consumers. VISION DESIGNATION BOARD An industry-wide facilitator of a trusted, simple and sustainable healthcare data exchange that evolves and aligns with market needs. Named by Secretary of HHS to be national author for operating rules mandated by Section 1104 of the Affordable Care Act. Multi-stakeholder. Members include health plans, providers (some of which are appointed by associations such as the AHA, AMA, MGMA), vendors, and government entities. Advisors to the Board include SDOs CAQH, All Rights Reserved. 18

19 CAQH CORE Operating Rule Overview CAQH CORE is the HHS-designated Operating Rule Author for all HIPAA-covered transactions, including Claims Attachments. HIPAA covered entities conduct these transactions using the CAQH CORE Operating Rules. Phase I Phase II Phase III Phase IV Transactions Eligibility Eligibility Claims Status Electronic Funds Transfer Electronic Remittance Advice Health Claims Referral, Certification and Authorization Enrollment Premium Payments Manual to Electronic Savings per Transaction (2017 CAQH Index) $6.46 Claim Status: $7.98 Claim Payment: $0.88 ERA: $4.14 Claim Submission: $2.35 Prior Authorization: $6.84 Notes: (1) All Active Phases include requirements for acknowledgements, e.g., 999 Functional Acknowledgement, 277CA Claims Acknowledgement. (2) CAQH CORE is also evaluating maintenance areas and opportunities to build on existing rules to support value-based payment. (3) Operating rules for eligibility, claim status, EFT, ERA, claims, enrollment, premium payment, and referral, certification and authorization support the HIPAA mandated transactions CAQH, All Rights Reserved. 19

20 2017 CAQH Index Report Medical Industry Electronic Transaction Adoption Claim Payment Remittance Advice 2018 CAQH, All Rights Reserved. 20

21 CAQH CORE EFT & ERA Operating Rule Requirements EFT & ERA Operating Rules Phase III CAQH CORE Operating Rules for the Electronic Funds Transfer (EFT) and Health Care Payment and Remittance Advice (ERA) transactions are federally mandated, except for rule requirements pertaining to Acknowledgements. INFRASTRUCTURE DATA CONTENT CAQH CORE 350 CAQH CORE 370 CAQH CORE 380/382 CAQH CORE 360 Health Care Claim Payment/Advice (835) Infrastructure Rule Includes CAQH CORE Master Companion Guide. Requires CAQH CORE Connectivity Rule. Details batch acknowledgement requirements. EFT/ERA Reassociation (CCD+/835) Rule Addresses provider receipt of the CAQH CORE-required minimum ACH CCD+ Data Elements required for reassociation as well as elapsed time between sending and receipt. Determines requirements for resolving late/missing EFT/ERA transactions. EFT & ERA Enrollment Data Rule (380 & 382) Identifies a maximum set of standard data elements for EFT enrollment. Requires health plan to offer electronic EFT enrollment. Requires providers to specify how payments should be made. Uniform Use of CARCs & RARCs (835) Rule Identifies four CAQH COREdefined Business Scenarios with a set of required code combinations that convey details of the claim denial or payment to the provider CAQH, All Rights Reserved. 21

22 Benefits of CAQH CORE Phase III EFT & ERA Operating Rules Key Benefits Improves cash flow via expedited payment and remittance reconciliation through the receipt of electronic payments and remittances. Eliminates the need for manual re-keying of reconciliations of EFTs and ERAs by requiring a trace number that links the two transactions. Increases ability to conduct targeted payment issue follow-ups through uniform and maintained ERA codes (CARCs, RARCs, and CAGCs). Standardizes enrollment for EFT/ERA so providers can sign up for both EFT and ERA electronically. Automates re-association of EFT and ERA leading to efficiencies and reduced errors. Saves an estimated $300 million and $3.3 billion per year* for providers including hospitals and health systems and health plans. * Administrative Simplification: Adoption of Operating Rules for Eligibility for a Health Plan and Health Care Claim Status Transactions 2018 CAQH, All Rights Reserved. 22

23 CARCs & RARCs Need for CAQH CORE Code Combinations Maintenance CAQH CORE is responsible for maintaining the CORE Code Combinations via the CORE Code Combinations Maintenance Process. There was extensive confusion throughout the healthcare industry regarding the use of the codes. CARC Claim Adjustment Reason Codes Provides the reasons for positive/ negative financial adjustment to a claim. Maintained by ASC X12. Providers did not receive the same uniform and consistent CARC/RARC/CAGC combinations from all health plans requiring manual intervention. Decisions on the CARC and/or RARC used to explain a claim payment business scenario were left to the health plans, lending a high level of subjectivity and interpretation to the process. RARC Remittance Advice Remark Codes Provides supplemental information about why a claim or service line is not paid in full. Maintained by CMS CAQH, All Rights Reserved. 23

24 CAQH CORE Code Combinations Maintenance Code Combinations Task Group Compliance-based Reviews Occur 3x per year. Include only adjustments to align updates to published code lists. Most Recent Publication: CORE Code Combinations v3.5.1 in October Market-based Reviews Occurs every other year. Consider only adjustments to address evolving industry business needs. Open to all HIPAAcovered entities. CORE Business Scenario 1 CORE Business Scenario 2 CORE Business Scenario 3 CORE Business Scenario 4 Additional Information Required Missing/Invalid/ Incomplete Documentation Additional Information Required Missing/Invalid/ Incomplete Data from Submitted Claim Billed Service Not Covered by Health Plan Benefit for Billed Service Not Separately Payable (376 code combos) (413 code combos) (905 code combos) (66 code combos) 2018 CAQH, All Rights Reserved. 24

25 How The CORE Code Combinations Benefit Providers Standardized use of CORE Code Combinations Providers are able to use the same CARC and RARC combinations electronically with all health plans. Key Benefits Potential reduction in manual claim rework With health plans more consistently using denial and adjustments codes per the CORE-defined Business Scenarios, providers have less Click to add rework. title Reduction in A/R days Automated and timely reassociation of EFT and ERA lead to efficiencies and reduced errors for payment posting. Denial Management is Expensive and Time Consuming Two out of three denials are recoverable (Advisory Board, 2014) Average cost is $25.00 and 71 minutes per denial (MGMA, 2018) Typical denial rate is 5-10% but rates for individual payers, codes or claim types can be much higher (AAFP, 2015) Historically, CMS denies 9.9% of claims (CMS blog, 2016) 2018 CAQH, All Rights Reserved. 25

26 Vendor(s) Vendor(s) CAQH CORE Resources to Support Providers Implementing EFT & ERA Health Plan Provider Claims Processing ERA Standard (835) Billing & Collections EFT Standard (CCD+/TRN) Treasury Bank Bank Treasury Resources Assess Organizational Readiness/Compliance -- Use CAQH CORE Analysis and Planning Guide Request Healthcare EFT Payments from Payers -- Use Sample Provider EFT Request Letter Contact Financial Institution to Request EFT, Including Reassociation Trace Numbers -- Use CAQH CORE Sample Provider EFT Reassociation Data Request Letter Ensure Vendor Alignment with CAQH CORE Operating Rules -- Encourage Vendor Become CAQH CORE Certified 2018 CAQH, All Rights Reserved. 26

27 Potential Solution with Streamlined Enrollment CAQH EnrollHub Trusted, secure solution from CAQH successfully engages providers. Multi-plan enrollment and ability to manage banking data in one place encourages provider participation. 200,000+ TINs (600,000+ providers) in system offer immediate matches for most plans. Plans increase data quality and eliminate verification and pre-note work. Industry-wide solution benefits all plans and providers. More information available at CAQH, All Rights Reserved. 27

28 Polling Question #1 Please indicate the extent to which your organization sends or receives health care payments through EFT (ACH Network only). Never (0% of the time). Occasionally (1% - 35% of the time). Sometimes (36% - 50% of the time). Often (51% - 90% of the time). Always (91% - 100% of the time) CAQH, All Rights Reserved. 28

29 OhioHealth Implementer Experience

30 OhioHealth Presenters Stephanie Glass Director Revenue Cycle Corporate Cash Posting 16 year in the HealthCare Industry 1.5 years at OhioHealth Randy Gabel Sr. Director Revenue Cycle Insurance Billing and Cash Posting 32 years in the HealthCare Industry 8 years at OhioHealth in Revenue Cycle and Information Technology 30

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33 Reconciling Deposit to Posting Process (BRP) Bank Deposits (B) Remittance (R) Payment Postings (P) Obtain a daily bank deposit detail report for patient related deposits Match remittance amounts to bank deposits If B=R and R=P then B=P (BRP) Validate that cash posted = remittance amount 33

34 Doctors Dublin Grant Riverside Riverside OH Lab Grady Hardin Hardin Marion Marion MGH Lab HomeReach Hospice ACVNA ACVNA OPG OPG Urgent Care ORPS MAP O'Bleness Mansfield/Shelby ERA Available EFT Available ERA/EFT Tracking Legend ERA/EFT Available 1 ERA & EFT Y ERA or EFT is available from payor 2 EFT- No ERA N ERA or EFT is not available from payor 3 ERA-No EFT 4 No ERA-No EFT 5 ERA-Some EFT 6 EFT-Some ERA 7 Some EFT-Some ERA NA Not Applicable/No payments received Payer Comments 1199 SEIU Y Y Ohio Comp N N BWC 3-Hab N N BWC 3P ADMINISTRATORS NA NA NA NA NA NA NA NA NA NA NA NA NA NA N N Zelis Enrollment Required 4th District IBEW Health Fund N N AARP Y Y Absolute Total Care Y Y ADMINISTRATIVE CONCEPTS, INC N N Zelis Enrollment Required Advanced Drainage Systems, Inc - Health Plan Account NA N N Advantage Health NA Y Y Adventist Risk NA Y Y Aetna Y Y AETNA ASA PPO/ASSURANT HEALTH NA Y Y AETNA BETTER HEALTH OF KENTUCKY Y Y AETNA BETTER HEALTH OF OHIO NA NA NA NA Y Y AETNA BETTER HEALTH OF PENNSYLVANIA NA NA NA NA NA NA NA NA NA NA NA NA NA NA Y Y AETNA BETTER HEALTH OF WEST VIRGINIA Y Y Aetna Genworth Y Y Aetna HCC NA Y Y Aetna Health and Life Insuarnce Company NA Y Y Aetna SSI Y Y Affinity Consulting Group NA Y Y AFLAC Y Y 34

35 Analysis by Deposit Transactions May 31, 2018 September 30, 2018 ERA/EFT Opportunity by Transactions ERA/EFT Opportunity by Transactions 19% 6% 18% 57% Offer EFT & ERA Offer EFT No ERA Offer No EFT No ERA Unknown 23% 7% 12% 58% Offer EFT & ERA Offer EFT No ERA Offer No EFT No ERA Unknown Offer ERA/EFT by Transactions Offer ERA/EFT by Transactions ERA & EFT ERA & EFT 15% 9% 42% EFT- No ERA ERA-No EFT 12% 9% EFT- No ERA ERA-No EFT No ERA-No EFT 14% 56% No ERA-No EFT 27% ERA-Some EFT ERA-Some EFT 4% EFT-Some ERA 4% EFT-Some ERA 3% Some EFT-Some ERA 5% Some EFT-Some ERA 35

36 Analysis by Payers May 31, 2018 September 30, 2018 ERA/EFT Opportunity by Payer ERA/EFT Opportunity by Payer 1% 27% 21% 4% 48% Offer EFT & ERA Offer EFT No ERA Offer No EFT No ERA Unknown 24% 22% 3% 50% Offer EFT & ERA Offer EFT No ERA Offer No EFT No ERA Unknown Offer ERA No EFT 36

37 Successes and Challenges Successes Completed Electronic Posting Transactions 98.5% Hospital (4.7k transactions)» Oct % (8.9k transactions) 99.6% Physician (1.4k transactions)» Oct % (19k transactions) Reallocated 20% of posting associates to other areas of need Automated cash reconciliation process with Finance In Process Investigating line item posting for hospital claims Auto-posting remits Challenges Creating a process Payer contracts with vendors Virtual payments Technology Volume Managing multiple TINs 37

38 Polling Question #2 Please indicate the extent to which your organization sends or receives remittance advice data using the ASC X12 v Never (0% of the time). Occasionally (1% - 35% of the time). Sometimes (36% - 50% of the time). Often (51% - 90% of the time). Always (91% - 100% of the time) CAQH, All Rights Reserved. 38

39 Audience Q&A Please submit your questions Enter your question into the Questions pane in the lower right hand corner of your screen. You can also submit questions at any time to Download a copy of today s presentation slides at caqh.org/core/events Navigate to the Resources section for today s event to find a PDF version of today s presentation slides. Also, a copy of the slides and the webinar recording will be ed to all attendees and registrants in the next 1-2 business days CAQH, All Rights Reserved. 39

40 Become a CAQH CORE Participating Organization to Maximize Impact Healthcare administration is rapidly changing. Be a part of CAQH CORE s mission to drive the creation and adoption of new healthcare operating rules. Represent your organization. Work with others around the industry. Communicate to industry partners and with your organization s leadership. Present on CAQH CORE education sessions. Upcoming opportunities: Testing & Certification Subgroup and Technical Work Group for Prior Authorization Click here for more information on joining CAQH CORE as well as a complete list of Participating Organizations CAQH, All Rights Reserved. 40

41 Thank you for joining Website: The CAQH CORE Mission Drive the creation and adoption of healthcare operating rules that support standards, accelerate interoperability and align administrative and clinical activities among providers, payers and consumers CAQH, All Rights Reserved. 41