Healthcare Payment

1
Healthcare Payment Remittance Medical Banking
- Best Practices

• Art Conklin, Director of FirstProxy and
• Electronic Payment Services

2
Electronic Healthcare Payment Session Objectives

• Overview of medical banking models in the
  healthcare payment and remittance marketplace
• Exploring best practices with an eye on
• ROI
• Inter-operability
• Auditing
• Reconciliation
• Context emerging marketplace

3
The Electronic Healthcare Payment Critical
Success Factors
Connectivity is the key

• Transaction flow controls
• Operational efficiencies, savings and profitable
  revenues.
• Reconcile billed to paid.
• Reconcile financial to administrative, the ERA to
  the EFT.
• Efficient Customer Support

4
The Electronic Healthcare Payment Managing the
Critical Control Points
Fitting the pieces together

• Transaction standards
• Systematic reconciliation
• On-line ERA management tools
• Consistent operational practices, such as
  enrollment
• Linking ERA and EFT
• Meaningful adjudication codes
• Purging the paper and handling

5
Healthcare Electronic Payment Models

• Standard healthcare claim and payment
• Provider to Plan to Provider
• Combining the administrative (ERA) and financial
  payment transactions (EFT)
• Outsourcing payment components
• Consumer driven plans and healthcare funds
• Greater member responsibility for selecting
  services allocating payment.

6
Standard Electronic Healthcare Payment Cycle
Provider
Healtcare service to patient
Payment ERA/EFT Reconciliation
Claims Submission
Claim Payment Life Cycle
Clearinghouse
Payment Remittance Advice EFT/Check
Payer Adjudication
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The Standard Electronic Healthcare Payment Model

• Clearinghouses process 835 from Payer to
  Providers
• Payers bank processes EFT to Providers bank
• Support Vendor Intermediaries
• On-line management support tools.
• Building partnerships to provide quality, value
  add products services.
• Priced to produce savings and profitable
  revenues.

8
Combining Administration and Financial
Transactions
FirstProxy
Print and mail
ERA
EFT
Provider Database
Reconciled
ERA
Electronic payment
Payer
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Combining the Electronic Healthcare Payments
Administration and Financial Transactions
FirstProxy

• EFT capability through ERA.
• ERA-EFT reconciliation.
• Single management tool for both payment
  transactions.
• Consistent operational workflow
• Efficiencies multiplied
• Fully outsourced payment functions

10
Combining the Electronic Healthcare Payments
Administration and Financial Transactions -
Challenges
FirstProxy

• Realignment of traditional partnerships in
  managing healthcare payments.
• Slower than expected market acceptance to
  outsourcing payment function.
• Final completion of Phase 1 of HIPAA Transactions
  
• Recognition of value equation

11
Electronic Payments in Consumer Driven Health
Plans and Funds
Provider
Healthcare service to patient
Payment Authorization / funds transfer Fund /
plan eligibility fund withdrawal
Eligibility / benefit verification
Fund Payment Life Cycle
Clearinghouse
ACH
Clearinghouse
ACH
Payment Remittance Advice EFT/Check
Fund / Plan Administrator
ERA Electronic Remittance Advice
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Electronic Payments in Consumer Driven Health
Plans and Funds

• Multi purpose benefit card is emerging to handle
  member payment responsibilities in consumer
  driven health plans and funds.
• Credit / Debit of accounts
• Administrative transactions, e.g. eligibility /
  benefit verification.
• Fits into provider workflow.
• Newer technology for POS devices permits for
  larger data requirements.

13
Electronic Payments in Consumer Driven Health
Plans and Funds Value Add Opportunities

• Credit funds beyond debit accounts.
• Claim submission as component.
• Integrated eligibility and benefit verification
  to determine who is responsible for what of the
  treatment costs.
• Advance payment for plans payment
  responsibility.

14
Electronic Healthcare Payment Summary

• Electronic payment with value-added services
  (i.e. Web management tool).
• ERA/EFT combination via strategic partnership.
• Multi-purpose benefit card support.
• Value add products services where opportunities
  exist.
• Priced according to value.

15
Appendices
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Traditional Electronic Payment Workflow
ERA/EFT Process
Payer Gateway data translator (ANSI 835), ANSI
edits connectivity
Payer Gateway data translator (ANSI 835), ANSI
edits connectivity
Payer claims receipt
Claims adjudication
Accounts Payable
ERA preparation
Payer banking interface
Clearinghouse batching, consolidation and/or
splitting logic
Funds transfer
Payer Gateway data translator (ANSI 835), ANSI
edits connectivity
Banking institution EFT transaction creation and
routing
Provider bank
Reconciliation
Online EPP
Network
Manual posting
Payer Gateway data translator (ANSI 835), ANSI
edits connectivity
Clearinghouse batching, consolidation and/or
splitting logic
ERA preparation
PMS posting software
Providers proprietary software posting
Provider Accounts Receivable
Provider claims submission
16
17
Healthcare Account Debit Flow
POS Technology
Payer Gateway data translator (eligibility/benefit
verification ANSI 270/271) edits connectivity
Payer Gateway data translator (ANSI 835), ANSI
edits connectivity
Eligibility / benefit plan
Enrollment / plan and fund set-up
Payer banking interface
Plan Sponsor Gateway data translator (ANSI
834), ANSI edits connectivity
Funds transfer
Payer Gateway data translator (eligibility/benefit
verification ANSI 270/271) edits connectivity
Banking institution EFT transaction creation and
routing
Provider bank
Financial debt
Funds transfer
Plan Sponsor Gateway data translator (ANSI
834), ANSI edits connectivity
Plan Sponsor Fund
Provider office POS (card swipe) device
ERA Electronic Remittance Advice
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Summary

• ProxyMed is the nations ONLY full suite of
  healthcare business solutions, offering
  beginning-to-end solutions.
• Transform the remittance advice and payment
  process from paper-based to electronic, resulting
  in
• Automated healthcare claims payment and
  settlement processes
• Improved efficiency
• Reduced costs
• Verify eligibility and benefit information prior
  to administering healthcare services, resulting
  in
• Improved administrative overhead
• Better cash management
• Expedited payment

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ProxyMed Can Help You Achieve Success By

• Enabling you to focus on core competencies

• Maximizing profits through increased efficiencies

• Expediting payment process

• Increasing productivity by reallocating resources

• Functioning as your single source for all
  administrative transactions

• Enabling you to focus on core competencies

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