NACHA April 30, Jan Root, PHD, CEO, Utah Health Information Network Henry Gardner, MHA, CTP, CHFP, VP Zions Bank

Transcription

1 NACHA April 30, 2012 Jan Root, PHD, CEO, Utah Health Information Network Henry Gardner, MHA, CTP, CHFP, VP Zions Bank

2 2 Healthcare Challenge Information Before Payment Option During After Healthcare s challenge is what surrounds the payment itself Before, During, and After

3 3 Healthcare Healthcare is based on a biological system Our knowledge of it is rapidly expanding and changing Very complex (maybe the most complex) data and information

4 4 Healthcare Data Clinical codes: Hundreds of thousands of units, measurements, codes LOINC (~ 65,000+), SNOMED (~300,000+), RXNorm (~500,000,) NCD (~500,000,), Constantly expanding (e.g., hundreds of new drugs each month) Some areas not yet coded (allergies) Billing codes: Typically a highly simplified version of clinical coding ICD-9/ICD-10, CPT, HCPCS, ASA, DRG Dental, vision, other specialty codes A great deal of text (notes): not machine consumable

5 5 Healthcare Information Using data actionable information Billing Example: Combining Diagnoses Procedures Codes Information about the person PROBLEM! Uterine cancer Hysterectomy Gender = male The combinations of data to create meaningful information are nearly infinite Our understanding of how to derive information is constantly changing

6 6 Healthcare Billing Data Healthcare data is rapidly changing Example: ICD = International Classification of Diseases US will be migrating from ICD-9 to ICD-10 in 2014 Will cause a HUGE billing disruption Providers need new coders (ICD-10 is completely different than ICD-9) Carriers and Providers will worry that new codes will impact payments

7 7 Healthcare Billing Data Federal requirements for billing just changed claims Has created a huge disruption in billing Not a matter of just crosswalking one format to another

8 Stakeholder Carrier (Provider Networks) 8 Carrier B Carrier A

9 9 Stakeholder Carrier Maintain complex data systems Negotiate with care providers Accept financial risk of a changing patient population Adjudicate claims Make payments supported by data Provide subscribers and providers with accurate explanations Comply with regulations

10 10 Stakeholder Provider Carrier A Carrier C Carrier B Carrier D

11 11 Stakeholder Provider Maintain complex data systems Diagnose patient problems and prescribe a solution Convert diagnosis and solution to billable codes Negotiate carrier reimbursement Reconcile each carrier s payment with its unique explanation Provide service without knowledge of payment amount, from where, how much, or when Comply with regulations

12 12 Spreadsheet example Provider/Patient Elements (Example) Patients A B C D E XXX YYY ZZZ Uninsured Self Pay Y Charity Insured Y Y Y Y Y Y Type Insur Health Auto Health Dental Health Insurer Happy H. All Insur. Dental South Insurer Plan B Auto C A Plus In Netowrk Y NA Y Y N Co-Pay Individ. Deductible Family Deductible Max out of Poket % Shared 20/80 20/80 20/80 20/80 30/90 HAS N NA N N N FSA Y NA N Y Y Covered N Y N N Y Secondary Insur. Y N N N LTD Secondary Insurer Allied Home Care People Allied Proceedures/Service Coding DRG CPT CPT DRG DRG Remit. Adv. Form Paper 835 Paper Paper Paper Payt. Form Paper ACH Paper ACH ACH Billing Form Hosp Ambulatory Pharma Dental AMB. Assigned To: Hosp Phys Practice Dental Phys

13 13 Baby Jane - Physician Insured Y/N Coding Claim Submission Insurer Happy Insurance Procedure Electronic/837 Plan A/B Co-Pay $35/N

14 14 Baby Jane - Carrier Claim Received Covered Procedure Provider in Network Patient Covered? % Share Contractual Payment Arrangement Plan A/B Max Out of Pocket Payment- ACH Co-Pay Deductible Paper Remittance Advice Payment and Advice to Physician

15 15 Baby Jane - Physician Submitted Payment ACH Payment- Remit Advice/Paper Single Claim Multiple Claims Matched Claims Payment Remit Advice Claims Payment Remit Advice Paid Contractual Patient Multiple Submissions Multiple Paid Multiple Patients PLB

16 Remittance Advice: 16 Single Claim

17 17

18 Remittance Advices to a Provider from 10 Carriers- All Similar, but Different 18

19 19 The Good News 30 Days Later Baby Jane is better. Baby Jane s physician is still trying to put together the payment pieces from Baby Jane s visit.

20 Call to Action: Where can I make a difference? 20 Submitted Matched Claims Paid Contractual Single Claim Payment Patient Remit Advice Payment ACH Payment- Remit Advice/Paper Multiple Submissions Multiple Claims Matched Claims Payment Remit Advice Multiple Paid Multiple Patients Additional

21 21 Why do Banks Care? Banks are increasingly becoming involved in the healthcare payment cycle Banks need to understand the existing healthcare payment cycle Banks have the potential of making this more complex Banks that handle healthcare data typically become HIPAA covered entities

22 22 UHIN Created standards on top of the federal administration standards which are more fine-tuned Providers and payers discuss and resolve problems together Approximately 70 published Standards Reduced cost of exchanging administrative healthcare data Working on a claim attachment standard

23 23 NACHA Set Standard for ACH payments Allows for elimination of a lot of paper Makes account reconciliation easier Re-association of ACH and healthcare remittance advices

24 24 Conclusion Healthcare payment cycle is extremely complex Complex healthcare data Integrally involved in payment issues Complex contractual arrangements Providers are left with unmanageable complexity Challenge: Can you make this better?

25 25 Thank you! Jan Root, Ph.D. CEO UHIN x203 Henry Gardner VP, Strategic Accounts Group Zions Banks