Group 3 Flip Chart Notes

Transcription

1 MDH-DLI Sympsium -- Meeting Mandates, Making the Cnnectin: Wrkers Cmpensatin Electrnic Health Care Transactins -- Nvember 5, 2014 Grup 3 Flip Chart Ntes Meeting Mandates, Making the Cnnectin: Wrkers Cmpensatin Electrnic Health Care Transactins Nvember 5, 2014 Abut the ntes in this dcument: During the sympsium abve, fur simultaneus smaller grup discussins were cnducted t help identify and address challenges and pssible slutins t wrkers cmpensatin electrnic health care transactins. The nte-taking n the flip charts during the discussins was intended primarily t help quickly capture high-level cmments, pints, r questins, but was nt intended t capture the full extent and depth f the cnversatins. Fllwing the sympsium, MDH and DLI staff typed up the ntes and, as requested by sme participants, are making them available t sympsium attendees with the acknwledgment that they are likely a helpful, but self-limiting, incmplete recrd. In additin, the fllwing ntes shuld nt be cnstrued as representing the views, psitins, r plicies f the Minnesta Department f Health (MDH) r the Minnesta Department f Labr and Industry (DLI). The first line f ntes under each categry is what the grup discussed in Sessin #1. The Secnd indented infrmatin reflects slutin suggestins, which were given in bth Sessin #1 and Sessin #2. 1. Patient Registratin and Care Patient des nt knw/state it is Wrk Cmp when they present. Need t ask patient at Registratin if it is a Wrk Cmp related visit. Claim #s d nt match Need t ask at Registratin if this is a new claim r a reccurring visit fr previus Wrkers Cmp claim s get crrect #s. Claims being billed withut all the crrect infrmatin, because the crrect infrmatin is nt cllected at Registratin. Sme Vendrs setting up Wrk Queue fr Wrkers Cmp s it desn t g ut the dr t bill until attachment and all infrmatin is accurate. Issue f wrng Payer ID n claim. Often wrksites use a different payer fr wrk cmp claims than general health claims (r an intermediary insurance payer fr wrk cmp). Als, different wrksites may a different Payer ID fr the same Payer, s need the wrksite s address. Fr example, McDnalds in ne lcatin may be a chain and have ne payer ID fr the wrkers cmp insurance, but anther McDnald s is independent and may use the same insurance cmpany, but has a different payer ID. S need Wrksite name, address, and crrect Wrk Cmp insurance payer infrmatin. One Prvider giving all Wrk Cmp patients an infrmatin packet at Registratin t be cmpleted by the emplyer and faxed t the prvider and the bill is held until this is received, r after prviders max days (5-7), the patient is billed usually this will get a respnse in a timely manner. Wuld like ne payer ID per Payer is this pssible? Issue f payer ID assciated with a different cmpany name than the Cmmn Cmpany Name. Discussin f which ID t use thrughut prcess Payer ID, Tax Payer ID, r Page 1 f 5

2 MDH-DLI Sympsium -- Meeting Mandates, Making the Cnnectin: Wrkers Cmpensatin Electrnic Health Care Transactins -- Nvember 5, 2014 Grup 3 Flip Chart Ntes OEID. Currently Payer ID is set up by Wrksite Emplyer ID. Need t mve t 837 versin that supprts dwn t the wrksite address t identify Payer ID. Bring Payers tgether t identify best ID t use, and which field t put this in. Suggested the clearinghuse wuld put the number in that field. Sme prviders will ask patient at Registratin fr the name f the cmpany n their paycheck. State Department shuld add the Payer ID. Claim number (needs t be used, and matched, at clearinghuse), DOB, Date f Injury, Patient Name, and Payer ID used fr claim identificatin. Need rule abut which nes and hw many are required fr matching. Need a best practice fr frnt desk Registratin staff. Need patient Educatin n prcess. Issue f needing vendrs/prviders t clean up Master File, using synnyms when tw different names are used cmmnly fr the same wrksite r payer. The systems d nt have the accurate payer IDs, as they change. Wuld like Pint f Cntact infrmatin fr patient t be able t tell them what is cvered by Wrker s Cmp and what is nt cvered by Wrker s Cmp at the time f Registratin. Smetimes patient des nt tell Registratin staff that the visit culd be Wrker s Cmp related, s a general health claim is filed. Patient files a Wrker s Cmp claim a few days later, and prvider desn t find ut until the initial bill is declined. Lack f cmpliance t electrnic billing requirement because it is easier t get the claim by sending paper than trying t figure ut what happened t the claim. 2. Create e-bill (837), attachments Pharmacy (and ther Specialists) get e-prescriptin (r referral fr MRI, prvider fllwup) but are nt infrmed that the visit is t be cvered under a Wrker s Cmp claim (r given the claim number), s they are filling bills under patient s general pharmacy insurance card nly t get denied and have t seek infrmatin frm initial health surce and rebill. This is a very manual prcess. i. Need indicatr n e-script message if Wrk Cmp visit s will be crrectly billed (n c-pay) the first time. Attachments are nt ready until health care prviders have cmpleted chart ntes each prvider system needs t identify if they will 1.) hld the bill fr a cmpleted attachment, link the tw and send tgether, r 2.) send the bill t a clearinghuse, which will hld the bill until the attachment is sent (smetimes by a different system f the prvider), and the clearinghuse links the tw and sends t the next clearinghuse r payer. It can take >75 days t find ut whether a charge is cvered r nt by Wrker s Cmp, r that it used t be, but has changed, s prvider has t rebill. Page 2 f 5

3 MDH-DLI Sympsium -- Meeting Mandates, Making the Cnnectin: Wrkers Cmpensatin Electrnic Health Care Transactins -- Nvember 5, 2014 Grup 3 Flip Chart Ntes i. Need tracking system t identify where each claim is. Claim number rules f are different between ClearingHuse(s) and prviders. X-12 transactin specifies 50 character maximum, with n specifics n alpha/numeric. Sme prvider (r clearinghuse) system require specific alpha/numeric r >50 characters, s systems can t respnd, and claim is denied. Need ne set f rules fr claim numbers. Prviders drp bill t paper fr Wrker s Cmp because it takes t lng t get bill paid, and t much wrk t identify what, r where, the issue with the claim is. 3. Send e-bill (837), attachments Clearinghuse(s) asking fr prvider vendr t help clean the initial claim, t limit the initial denials. N standard fr claim matching and matching criteria. The name is ften nt a match. Clearinghuse uses claim number, but 3 rd party system desn t have the claim number, s prvider can t find ut what happened t initial claim. i. Need standard frmat fr attachments (CCDA, TIF, PDF, EXL, etc.) ii. Need standard transmissin methds fr 275 and EDI t carry the frmatted messages. Difficult t identify wh t talk t fr reslving electrnic claim issues. Nt all payers are excepting claims, even thugh it is legislatin. Need enfrcement. 837 requires SSN with a field value prvider may nt cllect SSN as an identifier, r patient may nt chse t give SSN, s need t identify standard value that wuld be allwed by all clearinghuses/payers s if the rest f the claim is clean, it will be prcessed. Sme are using 999 in unknwn SSN, but thers dn t accept this. If SSN is blank, bill is rejected. i. Need MN t identify default value fr SSN r make SSN ptinal in X Received e-bill (837) attachments Sme systems nt able t link attachments t the bill (at prvider r clearinghuse level). Difficult t find ut where prblem is. Takes a lt f time, smetimes need t pen tickets with multiple payers/clearinghuses, and each d nt have same infrmatin t be able t track dwn the claim. 5. Acknwledgement (receipt f bill TA1, 999, 277CA) 277AC needs a cde, n lnger uses text this is nt adpted by all clearinghuses/payers s need Standard/Reinfrcement f this transactin. Sme clearinghuses/payers nt sending any acknwledgement. Need standard and enfrcement. Sme will get the acknwledgement frm the clearinghuse, but after it leaves there, the prvider gets nthing frm the next clearinghuse r payer. Page 3 f 5

4 MDH-DLI Sympsium -- Meeting Mandates, Making the Cnnectin: Wrkers Cmpensatin Electrnic Health Care Transactins -- Nvember 5, 2014 Grup 3 Flip Chart Ntes i. Wuld like acknwledgement frm secnd r subsequent clearinghuse/payers t flw back t the prvider pssibly in reverse rder f initial transactin ii. Wuld like a tracking system like UPS t identify wh gt the claim, where it is sitting. iii. There is a field in 277CA (acknwledgement number) that will let them knw where the claim was received after it left the clearinghuse need t educate prviders where this is. iv. Transparency critical because f resurces. Need t knw where claim is withut pening multiple tickets. v. If Prvider calling Payer t find ut where claim is, they payer receives a Reject Reprt frm the Clearinghuse, which may give sme infrmatin this is nt electrnic at this time. Prvider desn t knw that the clearinghuse drpped the bill t paper and the attachments were held up. When trying t slve, prvider asked t print ut and resend attachments. If attachments faxed, still are nt linked t claim when sent t payer. Prvider needs t knw (thrugh acknwledgement) that the attachment is cnnected with the bill. Sme payers rejecting a claim thrugh 277, and think it is a denial. Shuld be accepting the bill and sending an 835 as a denial, with a crrect reasn. i. Payer educatin issue need t use business scenaris t identify and standardize message f hw each shuld be handled N rules fr Acknwledgements shuld send ne acknwledgement when claim is received, and anther acknwledgement when attachment is received (if sent separately) and matched t bill. Cncern as t why this wrks fr general health claims, but nt Wrk Cmp when patient gives crrect inf at beginning f prcess Registratin. Wrk Cmp payers are much smaller than general health claim payers, s may nt be using mst recent technlgy available 6. Bill prcessing, adjudicatin Bills are reduced because Wrker s Cmp has maximum fee allwed under specific CPT cdes. Prviders nt able t find ut why it was reduced. i. Educate prviders t use DLI website fr this inf. 7. Bill payment/remittance advice (EOB 835) EOB electrnic versin desn t match up with the claim des nt shw patient ID, $ amunt, etc. i. Suggestin t bring payers int prvider billing ffices t see the issues first hand Page 4 f 5

5 MDH-DLI Sympsium -- Meeting Mandates, Making the Cnnectin: Wrkers Cmpensatin Electrnic Health Care Transactins -- Nvember 5, 2014 Grup 3 Flip Chart Ntes Need standard cdes fr 835 reasns fr denial clearinghuses use ne set f cdes, but payers have their wn (larger set). i. Educate payers f 835 reasn cdes Bulk Check Prcess randm checks fr multiple claims cme smetime later than the EOB. i. Bulk Checks shuld cme with claim numbers that are assciated with the check and cme with paper EOBs f each s bill can be recnciled. ii. Prefer n paper Bulk Checks shuld send electrnically s n manual recnciliatin f bills. iii. There are already 835 rules written fr Overpayment Recvery and Crrectin/Reversal need industry wide educatin and enfrcement f these rules. Pssibly MN webinar with payers and 835 authrs. Virtual Payment (credit cards) prviders sent these credit cards by sme payers, with n ptin t nt use. i. Wrk with Attrney General t identify/educate/fine ii. Use Cmpact (quarterly articles) t educate n what can r can t be dne, Optut ptins, etc. Payers chsing paper r credit cards, nt EFT, with n ptins fr prviders. Shuld be electrnic. 835 des nt have check number n it that it ges with ften payer will send 835 befre the check is created s the check number is nt knwn. i. Suggest hld 835 until the check is created, and then include the check number n the 835. Sme payers want prvider bank accunt inf s they can directly remve (debit) inf if payer determines they have verpaid n an accunt. i. Need rule abut this nt apprpriate. ii. Instead, need 835 clean edit prcess Prvider nt ntified electrnically when clearinghuse/payer (1) has cmpleted bill check and claim sent n t anther clearinghuse/payer(2). If claim desn t balance, prvider shuld send Acknwledgement t clearinghuse, wh sends n t payer that it is incrrect. 8. Acknwledgement (receipt f EOB TA1, 999) Often nt get t this step because s many issues with Wrk Cmp bill that it is easier t print ff. Payers will change mind during prcess f a bill t pay differently than when bill initially sent. i. Need best practices fr Crrectins and Reversal. Page 5 f 5