EDI, ANSI 837 Files, & Clearinghouse 101

Transcription

1 EDI, ANSI 837 Files, & Clearinghouse 101 National Association of Community Health Centers (NACHC) 7200 Wisconsin Avenue, Suite 210 Bethesda, MD FAX

2 Agenda Introduction What is EDI Origins Paper vs. Direct Submission vs. Clearinghouse Pro & Con Analysis Clearinghouses A History What Is It Nuts & Bolts Transition to v5010 & ANSI 837 Files A Step by Step Process Example Best Practices & Tools for EDI Optimization Summary

3 Disclaimer: 1. The guidelines, interpretations, and recommendations set forth as part of this training session are presented as a guide only. Attendees understand and recognize that actual coding/billing decisions are the sole liability and responsibility of the provider(s) and respective billing staff. Neither NACHC nor Priority Management Group, Inc. accepts any liability or responsibility in this regard. 2. The presentation today includes discussion about a particular commercial product/service and the presenter may have a significant financial interest/relationship with the organization that provides this product/service.

4 Speakers: Ray Jorgensen, MS, CPC, CHBME Raymond T. Jorgensen is President and CEO of Priority Management Group, Inc. (PMG). Ray is responsible for oversight of consulting operations as well as coding, reimbursement, and payer related issues for the out-sourced billing component of PMG s services (more than one million annual encounters). He has personally trained thousands of providers from over 35 states on coding, billing, and reimbursement in addition to authoring two books and dozens of articles. Ray s health care experience and education is unique in that he was schooled by the payers. Having worked for Blue Cross and Blue Shield as well as United HealthCare Corporation, primarily in professional relations and contracting, Ray has an understanding and perspective on the payer s objectives and process unlike other medical business consultants groomed from the provider side. BA from The College of the Holy Cross (Worcester, MA) MS from Northeastern University (Boston, MA) CPC from the American Academy of Professional Coders (Salt Lake City, UT) CHBME from the Healthcare Billing & Management Association (Laguna Cliffs, CA)

5 Speakers: Caroline Peucker, CPC, CPC-H, CPC-I PMG s Vice President, Consulting and Compliance, Caroline has more than 25 years experience in the physician billing and coding industry. Her extensive experience includes serving as the Vice President, Coding and Compliance, Manager of coding and Billing Operations Manager for physician billing companies that serviced a wide range of specialties and practice types. She has broad experience with hospitalbased physician and private practice where she was integral to coding and compliance education and training for clinical providers, practice and billing office staff members. She has performed and managed chart audits with objective of both compliance and optimizing reimbursement through correct coding and thorough documentation. Caroline holds a Bachelor of Science degree in Health Service Administration from Providence College. She is an AAPC certified coder and PMCC instructor.

6 Speakers: Robert Skeffington, CHBME Robert Skeffington, a founding partner and Executive VP of Sales and Marketing for Priority Management Group, Inc. (PMG). Responsible for PMG s overall business development strategy, Robert also works with staff to assess the impact of Health Care Reform on PMG and its hundreds of clients. Robert works diligently to enhance relationships with the National Association of Community Health Centers, state and regional CHC organizations, and individual community health sites. In addition to his role in PMG Billing, Robert also leads marketing and sales efforts for PMG Consulting which provides CHC centric education, operational assistance, and training services around revenue cycle management, coding, and other health care finance related matters. During his more than 17 years in health care Robert has worked with CHCs in the 48 contiguous states with an exclusive focus on revenue cycle management for the past 12 years with PMG. He is a speaker for NACHC and other regional CHC associations on a variety of health care revenue cycle related topics. BS from Salve Regina University (Newport, RI) CHBME from the Healthcare Billing & Management Association (Laguna Cliffs, CA)

7

8 Clean Claims Objective: Paid all the money anticipated on first claim submitted CMS Billing Formats: 1500 (ANSI 837p; Part B/Professional) UB-04 (ANSI 837i; Part A/Facility and NGS) Top Reasons for Non-Payment Demographic Issues Eligibility Prior-Authorization Medical Necessity (ICD) First Pass Rate: Clearinghouse (EDI) Level Report Clean Claim Rate: Post Pay Adjudication

9 Converting Clinic Data to EDI ICD Codes In Order of Provider s Perceived Acuity: 1. Abscess: Acne: Warts: Psoriasis: Rendered Services: Linked ICD to CPT A (Level 3, established patient) 1, 2, 3, & 4 B (Any benign lesion destruction) 3 C (I&D, Simple) 1

10 Electronic Data Interchange (EDI): A History Paper Claims USPS Delivery Millions of providers sending claims to thousands of payers Billions of Claims Trillions of line items Proof of Receipt? Error Rate? Sustainability? Logistical madness The Birth of EDI Why? Computers & Practice Management Software Savings Money & Time Claim Complexity Payer Edits (e.g., CCI) Improved Accountability Local & Payer Centric Clearinghouses National clearinghouse roll up of local & regional entities

11 Note: Some content adopted from article by Michael J. Sculley A Clearinghouse What is it? Rectifying a problem; i.e., moving past a paper process Millions of licensed providers (billable NPI numbers) Thousands of third party payers Billions of claims resulting in trillions of line items USPS Managed for Years No edits, payers take all claims without exception Payers created clearinghouses Centralized aggregators as they just send & receive data Paid by providers AND by payers literally coming & going Claims bounce back BEFORE payers even see them Payer imposed edits (controls) to prevent faulty data receipt

12 A Clearinghouse Nuts & Bolts 1. Encounter form or EMR capture of patient visit is charge entered into practice management software 2. Claim is formatted into electronic file format 3. PM claim file is pushed or uploaded one of two ways: A. Direct to Payers B. To Clearinghouse 4. Clearinghouse scrubs claim based on payer guidelines 5. Claim either forwarded to payer or returned to provider for corrective action 6. Claim adjudicated by payer(s) 7. EOB/RA back to provider with payment status and (hopefully) actual payment Note: Some content adopted from article by Michael J. Sculley

13 A Clearinghouse Pro & Con Advantages of Going Direct FREE No Middleman Challenges of going direct Thousands of payers Complexity (Redundancy?) Help Desk Access PM Software Interface Updates Inability to aggregate claim data Conversion from v4010 to v5010 Advantage of Clearinghouse 24/7 Knowledge-Base Access Claim Advocate Pre-Submission Edits TAT Commitments Automated Forms Aggregated Claim Status Challenges of Clearinghouse Large Corporate Entities Unique CHC Claim Files Expensive (But Cost Effective) Note: Some content adopted from article by Michael J. Sculley

14 Transition to v5010 (1 of 3) ANSI Transaction Version 5010 (v5010) replaces v4010 ANSI: American National Standards Institute Electronic Data Interchange (EDI) transactions Impacted transaction types: Health Care Claims (format 837) Eligibility Inquiry and Response (format 270/271) Claim Status Request and Response (format 276/277) Enrollment format (format 834) Remittance Advance (format 835) Authorizations (format 278) Attachments (format 275) Version 5010: > 850 structural, technical, & content changes Renovation (v5010) versus mapping/adaptation (v4010)

15 Transition to v5010 (2 of 3) Payer Leadership Essential they run the show Only they can eliminate proprietary adaption and comply with single, standardized format Compliance Timeline (as of 1/16/09 final rule publication): Jan 2010: Level 1 testing (internal payer & provider (e.g., CHC)) Jan 2011: Begin Level 2 testing (external payer trading partners (e.g., clearinghouses, provider networks, etc.)) Jan 2012: Mandatory implementation Benefits: Increase transaction uniformity & efficiency (single standardized method versus v4010 which allowed customized mapping) Support pay-for-performance (ICD-10 specificity) Lead to fewer denials (Cleaner submission = cleaner payments)

16 Transition to v5010 (3 of 3) Center for Information Technology Leadership (CITL) 2001 study Aggregate of payer, hospital & practices on administrative overhead: $898 per capita or $253 billion (18% of national health care expenditures) Overhead defined as checking eligibility, processing claims and conducting referral and authorization requests Gartner (think tank) research estimated implementation costs against potential financial benefits of full v5010 (system wide compliance Industry wide (payer & provider) net savings: $11.6 billion to $33.8 billion HIPAA v5010: A second chance for the industry to implement transaction standards to reduce costs and increase efficiency. Healthcare Information and Management Systems Society (HIMSS), February 2009

17 Timelines for Change Initial schedule: 5010: Apr 2010 ICD-10: Oct 2011 Jan 2009 Revised Federal Register Update: 5010: Jan 2012 ICD-10: Oct : To Do list for providers Transition team development & needs assessment Individual plan creation & Launch Jan 2011 Testing of 5010 by CMS

18 ANSI 837 Claim Files ANSI 837-I I = Institutional Paper Version: UB-04 Qualifiers (Examples) HC: CPT; XX: NPI Encounter Rate (Part A) Revenue Codes CR 7038, HCPCS also Attending Provider Billable is FQHC group, not actual (rendering) provider ANSI 837-P P = Professional Paper Version: CMS 1500 Qualifiers (Examples) HC: CPT; XX: NPI Medicaid, Part B, & Commercial HCPCS Codes For Example, CPT Rendering Provider Billable is actual provider, not FQHC group

19 ANSI 837 Loops, Segments, & Elements Loops: First Identifier in 837 File Format Segments: Secondary identifier modifying or delineating the Loops Elements: Tertiary identifier modifying or delineating the Segments Analogy: Paragraph (Loops) Sentence (Segments) Word (Elements) File Viewer necessary to delineate raw 837 data Beginning of new line in raw data indicated by ~ Each Payer may have unique Companion Guide assigning unique definitions to these loops CHECK WITH COMMERCIAL & MEDICARE PAYERS

20 ANSI 837 Qualifiers BK = ICD Code (a.k.a., diagnosis or reason for visit code) EI = Employer Identification Number (e.g., EIN, Tax ID) HC = HCPCS (e.g., CPT) Code MI = Patient (Payer s Member) ID Number SY = Social Security Number XX = National Provider Identifier (NPI) ZZ = Taxonomy Code 82 = Rendering Provider 85 = Billing Provider

21 ANSI 837- Professional ISA*00* *00* *ZZ*RI105 *ZZ*MCC *110208*0143*U*00401* *1*P*:~GS*HC*SUBID*RECEIVER NAME* *0143* *X*004010X098A1~ST*837*0033~BHT*0019*00*0033* *0143*CH~ REF*87*004010X098A1~NM1*41*2*SENDER NAME*****46*SUBID~PER*IC*JANE NAME*****46*XYZ~HL*1**20*1~NM1*85*2*COMMUNITY HEALTH CENTER*****XX* ~N3*DBA COMMUNITY HEALTH CENTER*PO BOX 99999~N4*ANYWHERE*RI* ~REF*EI* ~HL*2*1*22*0~SBR*P*18*******MB~NM1*IL*1 *MOUSE*MICKEY****MI* A~N3*101 ANY DRIVE~N4*ANYWHERE*RI*12345~DMG*D8* *F~NM1*PR*2*MEDICARE*****PI*MCARE~N3*P O BOX 999~N4*WHOVILLE*GA*98765~CLM*447540*13***11::1*Y*A*Y*Y*B~REF*X4*99D ~HI*BK:2859* BF:71590*BF:4019~NM1*DN*1*SANBERG*JONAS*G**MD*XX* ~REF*EI* ~NM1*82*1 *SANBERG*JONAS*G**MD*XX* ~PRV*PE*ZZ*261QF0400X~REF*EI* ~NM1*77*2*CO MMUNITY HEALTH CENTER*****XX* ~N3*123 MAIN ST~N4*ANYTOWN*RI*12345~LX*1~SV1*HC:85018:QW*13*UN*1***1:2:3~DTP*472*D8* ~REF*6R *75572~HL*3*1*22*0~SBR*P*18*******MB~NM1*IL*1*DUCK*DONALD***JR*MI* A~N3*130 MAINST~N4*ANYTOWN*RI*12345~DMG*D8* *M~NM1*PR*2*MEDICARE*****PI*MCARE~N3*P O BOX 999~N4*WHOVILLE*GA*98765~CLM*447870*13***11::1*Y*A*Y*Y*B~REF*X4*99D ~HI*BK:V700~ NM1*DN*1*SANBERG*JONAS*G**MD*XX* ~REF*EI* ~NM1*82*1*SANBERG*JONA S*G**MD*XX* ~PRV*PE*ZZ*261QF0400X~REF*EI* ~NM1*77*2*COMMUNITY HEALTH CENTER*****XX* ~N3*12S MAIN ST~N4*ANYTOWN*RI*12345~LX*1~SV1*HC:81002*13*UN*1***1~DTP*472*D8* ~REF*6R*75616~ SE*60*0033~GE*1* ~IEA*1* ~

22 ANSI 837- Institutional ISA*00* *00* *ZZ*HM57570 *28*00450 *110211*0526*U*00401* *1*P*:~GS*HC*HM57570*00450* *0526* *X*004010X096A1~ST*837*0789~BHT*0019*00*0789* *0526*CH ~REF*87*004010X096A1~NM1*41*2*SENDOR NAME*****46*HM57570~PER*IC*JANE *2*MEDICARE*****46*00450~HL*1**20*1~NM1*85*2*HEALTH CENTER*****XX* ~N3*123 UNKNOWN ST~N4*ANYTOWN*RI*01234~REF*EI* ~HL*2*1*22*0~SBR*P*18******* MA~NM1*IL*1*MOUSE*MICKEY****MI* A~N3*P.O BOX 123~N4*ANYTOWN*RI*01234~DMG*D8* *M~NM1*PR*2*MEDICARE UGS*****PI*00450~N3*6775 WEST WASHINGTON STREET~N4*MILWAUKEE*WI* ~CLM*993170*136***77:A:1*Y*A*Y*Y *********Y~DTP*434*RD8* ~REF*EA*52427~HI*BK:25000~HI*BF:4011*BF:2722~NM1*71*1*SMITH*J OSEPH*M**MD*XX* ~PRV*AT*ZZ*207Q00000X~REF*EI* ~N M1*FA*2*HEALTH CENTER*****XX* ~N3*123 UNKNOWN ST~N4*ANYTOWN*RI* ~REF*EI* ~LX*1~SV2*0521*HC:99214* 136*UN*1~DTP*472*D8*

23 Step by Step: Ntierprise Example (1 of 10) VALIDATING CLAIMS Validating Electronic Claims 1. In Ntierprise go to Billing 2. Go to Insurance Billing 3. On the Validate Claims tab choose Electronic Format 4. Sort Claims By: Provider 5. Select Print Claims Validation List so you may correct any errors 6. Choose Run, then Preview

24 Step by Step: Ntierprise Example (2 of 10)

25 Step by Step: Ntierprise Example (3 of 10) The Claim The Claim Validation Validation List List will will populate. populate. This This may contain may errors contain that will errors need that to will need to be corrected be corrected in Ntierprise in Ntierprise in order for the in order claim(s) for to be the billed. claim(s) to be billed.

26 Step by Step: Ntierprise Example (4 of 10) When/if all corrections have been made, follow the above steps to create another validation with preferably no errors. If you do not validate after making corrections those claims will not be included in the next billing.

27 Step by Step: Ntierprise Example (5 of 10) VALIDATING PAPER CLAIMS 1. In Ntierprise, go to Billing 2. Go to Insurance Billing 3. On the Validate Claims tab choose Paper Format 4. Sort Claims By: Provider 5. Select Print Claims Validation List 6. Choose Run, then Print

28 Step by Step: Ntierprise Example (6 of 10)

29 Step be listed by in the Step: Failed Validation column. Ntierprise Example (7 of 10) Totals of the claims ready to be printed will be in the Passed column. If there are any errors they will be before the Total Summary and will also be listed in the Failed Validation column.

30 Step by Step: Ntierprise Example (8 of 10) COMPLETING A PREPARE To be completed after validating claims. 1. In Ntierprise go to Billing 2. Go to Insurance Billing 3. Prepare Electronic Claims tab 4. Highlight the format you are going to bill 5. Choose Run 6. Press Print

31 Step by Step: Ntierprise Example (9 of 10)

32 Now the prepare can be submitted to the clearinghouse so the claims can be sent to the payers. Step by Step: Ntierprise Example (10 of 10) The Prepared Claims List will populate. number On the of last claims page billed you will along find with the the total total number dollar amount of claims of the billed prepare. along with the total dollar amount of the prepare. The Prepared Claims List will populate. On the last page you will find the total

33 A Sample of Rejected EDI Analysis **EDI: Electronic Data Interchange 55% Denial due to Eligibility Issues

34 Better Sample of Rejected EDI Analysis

35 Front Desk Feedback: Sample CBO Communication

36 Best Practices & EDI Optimization Tools Consistent transmission timeline (frequency) Redundant systems Who has skills & access to written process Back-up players must get in the game CMS1500 conversion to 837P (Boxes to Loops) S1500.html# Rapid Response to EDI failures How do you catch it, fix it, & prevent repeat?

37 Summary EDI (e.g., ANSI 837 file) Format is consistent nationally EDI Process varies dramatically Use First Pass (Validation Failures) to educate staff and improve process/rules Work with Clearinhouse for v5010 transition Performance benchmarks are critical Automation is not always automatic Stay educated and informed

38 Contact Information Priority Management Group, Inc. (PMG) 700 School Street Pawtucket, RI P: F: Raymond Jorgensen, President & CEO Robert Skeffington, CHBME, Partner and Co-founder Caroline Peucker, Vice President, Consulting and Compliance