Electronic Medical Bill Processing Advances and Changes

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Electronic Medical Bill ProcessingAdvances and
Changes

• Allen McDonald
• Director, Information Management Services

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Texas Workers Compensation eBill Transactions
and Processes

• A Quick Refresher

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Labor Code 408.0251

• Requires the Commissioner, by rule, to adopt
  rules regarding the electronic submission and
  processing of medical bills.
• Requires insurance carriers to accept medical
  bills submitted electronically by health care
  providers in accordance with the adopted rules.
• Requires rules to include criteria for granting
  exceptions to insurance carries and health care
  providers.
• Added by HB7 (2005).

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28 Texas Administrative Code 133.500

• Adopts standard electronic formats for billing,
  acknowledgements, remittance advice, reporting
  and documentation.
• Medical billing transactions must contain all
  fields required in the format implementation
  guide and associated Division implementation
  guides.
• Permits non-prescribed formats by mutual
  agreement. All required data elements must be
  present.

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28 Texas Administrative Code 133.501

• Requires insurance carriers and health care
  providers to be able to exchange electronic data,
  unless they meet the waiver criteria.
• Establishes the waiver criteria.
• Defines complete electronic bill and complete
  electronic documentation.
• Establishes certain processing actions
• Electronic bills must be acknowledged within one
  business day.
• Limits duplicate electronic bill submission when
  acknowledged by insurance carrier.
• Prescribes five-day timeframe for
  remittance/payment advice.

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eBill Transactions

• A Quick Look At The Numbers

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Fall 2008 Data Call

• Data Call issued in Fall 2008 to select insurance
  carriers
• Over 4 million medical bills were processed with
  2008 dates of service

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Vendor Feedback 2009(Professional/Institutional)
Number of eBills Per Month
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Whats Behind The Numbers?

• Performance Varies Greatly
• Insurance Carriers
• Health Care Providers
• eBill Agents/Clearinghouses
• The most successful entities have implemented
  integrated solutions

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Key Differences Between Workers Compensation and
Health Insurance

• v.

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• Eligibility ID Card
• Policy limits, deductibles, and balanced billing
• Generally, documentation not required with claim
• HIPAA

• No eligibility ID Card
• No policy limits, no deductibles, no balanced
  billing
• Documentation key component of indemnity
  determinations

Health
W/C
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• Workers Compensation
• Key Data Differences
• Employer Name/Address
• Patient SSN
• Date of Injury
• State License Numbers
• Documentation

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Vendor Solutions

• Health Care Providers

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Medical Bills and Required Documentation(2009
Dates of Service)
Medical Bills Without Required Documentation
Medical Bills With Required Documentation
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Documentation Solutions

• Most vendors have integrated a fax-cover solution
  into their systems
• System-generated fax-cover sheets provide the
  documentation identification needed for matching

• Some vendors have document upload systems
• Requires subscription
• May require document conversion (scanning)
• Few vendors have EHR (Electronic Health Record)
  integrated solutions

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Web-Based Entry Solutions

• Several vendors have products to allow health
  care providers to enter claims on-line
• Some offer free access, others charge transaction
  fees

• Some offer document solutions, some do not
• All require data entry, but usually includes
  editing of data values and codes (reduces the
  number of rejected medical bills)

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Direct ConnectionSolutions

• Some insurance carriers have implemented systems
  to allow health care providers to directly
  connect and submit eBills
• Viable only for health care providers that have
  the information technology staff to support
  maintaining automation systems and connections

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Clearinghouse-to-Clearinghouse Solutions

• A few vendors have executed trading partner
  agreements and are in production with health care
  information clearinghouses
• Allows health care providers to use existing
  software and connectivity packages to submit
  eBills
• Documentation approach varies greatly
• No documentation solution
• Fax cover sheet solutions
• Electronic file upload solutions

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Practice Management System Integrated Solutions

• At least one vendor has implemented solutions to
  directly connect to PM Systems
• Allows for extract and upload from PM System to
  eBill agent

• Can be tailored for format and other PM system
  specific limitations
• Can support uploads of electronic health records

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Vendor Solutions

• Insurance Carriers

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Legacy Integration Solutions

• Some insurance carriers have contacted with
  vendors to receive a data feed of eBill data
• Does not require changes to existing (legacy)
  bill processing systems
• Data is mapped to the legacy system
• Data conversion may be required
• Formats may not align
• Some data will not be passed or stored

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Problems With Legacy Integration

• Legacy systems may not contain the data elements
  necessary for 835 generation or Medical State
  Reporting (e.g., NPI Numbers)
• Legacy systems may not contain the technical
  edits to accurately process medical bills

• For example, an insurance carrier continues to
  pay for the following HCPCS
• K0406
• M0010
• Y3700
• Y6370

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Bill Review Integration Solution
Bill Review Post Edit Review and Adjudication
Claims Processing Or URA
Accept/Reject
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Full-Service Solutions
eBill Bill Review Claims Processing State
Reporting
Claims Queue
Accept/Reject
State Reporting
URA
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Successful Solutions

• Business process focus
• Connectivity
• Health care information clearinghouses
• Practice Management System Vendors
• Other eBill agents
• Broad array of provider products

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Potential and Coming Changes

• Informal Working Draft Rules

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Purpose of Revisions

• Clarify and Specifically Identify
• Paper medical bill requirements
• Electronic medical bill requirements
• Documentation Requirements
• To the extent possible, align with standards used
  in the health industry

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Paper Bill Requirements

• Adopts CMS manual for professional and
  institutional medical bills
• Lists additional data elements required for
  workers compensation, including
• Patients Social Security Number
• Employers Name
• State License Numbers
• Lists data elements not required for workers
  compensation
• Eliminates need for separate clean claim
  instructions

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Required Documentation

• Changes definition of a complete bill to
  include required documentation
• Modifies language to clearly identify the
  services which require medical documentation to
  be submitted with the bill
• Adds provisions related to inappropriate denials
  for lack of documentation

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Requests for Documentation

• Requires the insurance carrier to include
• A description of the specific document or
  documents being requested and
• An explanation about the specific reason or
  reasons each document is needed
• Delivery addresses to enable confirmation of
  receipt
• Requires the insurance carrier to reimburse for
  requested documentation

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eBill Formats

• Adds transaction standards supporting the shift
  to ASC X12N 005010 and NCPDP D.O framework
• On/after January 1, 2012, adopts
• TA1 Interchange Acknowledgment
• 999 Implementation Acknowledgment
• 277CA Health Care Claim Acknowledgment

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eBill Requirements

• Modifies language to clearly require submission
  and receipt of electronic medical bills if the
  health care provider or insurance carrier do not
  have an exemption
• Modifies exemptions
• Modifies definition of received date
• Adds charge prohibition for closed systems
• Removes 7-day delay on electronic medical
  documentation

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Questions?
This presentation was produced by the Information
Management Services Section of the Division of
Workers Compensation, Texas Department of
Insurance, 7551 Metro Center Drive, Suite 100,
Austin, Texas, 78744 [phone]. This
information is for educational purposes and is
not a substitute for the statute and rules.