eBill Implementation

1
eBill Implementation

• Stakeholder Feedback
• And
• Discussion
• April 7, 2008

Allen C. McDonald, Jr. Director, Information
Management Services Division of Workers
Compensation Texas Department of Insurance
2
Purpose

• Provide summary information regarding
  implementation issues identified in other
  settings
• Receive feedback from eBill stakeholders
  regarding implementation
• Successes
• Best practices
• Challenges
• Problems
• Receive recommendations and input to address
  implementation issues

3
Agenda

• Background and information gathering approach
• Success stories
• Health care provider
• Insurance carrier
• eBill Agent/Clearinghouse
• Issues or challenges
• Open discussion

4
eBill Perception
Insurance Carrier
Health Care Provider
5
eBill Reality
6
Background

• Texas Labor Code 408.0251
• the Commissioner is required to adopt rules
  regarding electronic medical billing and waivers
  and
• insurance carriers shall accept medical bills
  submitted electronically in accordance with the
  adopted rules
• eBilling Rules adopted in July 2006
• 28 Texas Administrative Code (TAC) 133.500
• 28 TAC 133.501

7
28 TAC 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.

8
28 TAC 133.501

• Requires insurance carriers and health care
  providers to be able to exchange electronic data,
  unless they meet the waiver criteria.
• Defines complete electronic bill and complete
  electronic documentation.
• Allows the use of agents to meet eBill
  requirements.
• Establishes certain processing actions
• Prescribes timeframes, and
• Limits duplicate electronic bill submission when
  acknowledged by insurance carrier.

9
Companion Guides

• Version 1.0 of the Companion Guides was published
  April 9, 2007
• Stakeholders raised issues regarding the
  differences between Companion Guides and existing
  health industry standards
• Stakeholder meetings conducted in October and
  November of 2007
• Version 2.0 of the Companion Guides was published
  January 9, 2008

10
eBill Project Goals

• Align with national standards industry
  practices
• Leverage existing technology relationships
• Minimize workers compensation specific
  requirements
• Provide flexibility to trading partners
• Reduce administrative costs

11
Information Gathering

• Numerous brown bag education sessions
• Questions received by Division regarding
  implementation
• Focus Group Meetings
• Health Care Provider
• Insurance Carrier
• eBill Agent/Clearinghouse

12
Keys to eBill Success

• Outreach and Education
• Stakeholder Preparedness
• Interoperability
• Easy to Use
• Cost Effectiveness
• Electronic Documentation Management

13
eBill ImplementationSuccessStories
14
Health Care Provider

• Health care information clearinghouses have
  entered, or are entering, the workers
  compensation eBilling environment
• Accelerated development and release of products
  to support eBilling for workers compensation
  claims
• Use of mutually agreed upon formats has promoted
  connectivity and interoperability
• eBilling is occurring

15
Insurance Carrier

• One insurance carrier has experienced a 50
  increase in the number of bills submitted
  electronically
• Education and outreach efforts to health care
  providers have increased awareness and
  participation
• Some eBill agents and clearinghouses are not
  charging providers transaction fees to use
  particular products or approaches

16
eBill Agent/Clearinghouse

• Several insurance carrier eBill agents have
  executed data sharing agreements with
• Health care information clearinghouses and
• Other eBill agents
• Several eBill agents have experienced steady
  increases in the number of electronic bills
• Collaboration efforts, including the work with
  SeBIN, have successfully address some
  implementation challenges

17
eBill Implementation Issues or Challenges
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Required Formats

• Insurance carriers MUST accept electronic bills
  submitted in accordance with the rules
• ANSI ASC X12 837 (professional, institutional,
  and dental)
• NCPDP 5.1 (pharmacy)
• ANSI ASC X12 275 (attachments)
• Insurance carriers may allow mutually agreed upon
  formats, but cannot require a health care
  provider to use a different format

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Attachments

• May be submitted by
• Facsimile
• Email
• Electronic format (ANSI 275 or other mutually
  agreed upon format)
• Insurance carriers or their eBill agents must
  support all methods

20
Required Documentation

• The documentation required to be submitted with
  an electronic medical bill is only that
  documentation required by rule
• March 26, 2008 memorandum issued to help promote
  change and limit
• Improper denials by insurance carriers
• Improper submission by health care providers

21
Written Notice of Injury

• 28 TAC 133.501(c)(4) states Acceptance of a
  complete medical bill is not an admission of
  liability by the insurance carrier.
• 28 TAC 133.200(c) states
• The proper return of an incomplete medical
  bill in accordance with this section fulfills the
  insurance carrier's obligations with regard to
  the incomplete bill.

22
Connectivity

• Texas Labor Code 408.0251 requires insurance
  carriers to accept electronic medical bills
  submitted in accordance with the rules.
• 28 TAC 133.501 requires insurance carriers and
  health care providers to be able to
  electronically exchange medical billing data
• Some stakeholders have encouraged the TDI-DWC to
  allow market innovation to drive connectivity

23
Transaction Fees and Costs

• eBill agents and clearinghouses have indicated
  that the cost of conducting workers compensation
  transactions is different than in other health
  systems (primarily due to attachments)
• Some stakeholders have encouraged TDI-DWC to
  allow the market to drive the establishment or
  amount of fees

24
Responsibility for Agents

• 28 TAC 133.501(a)(4) allows health care providers
  and insurance carriers to contract with third
  party agents
• Health care providers and insurance carriers are
  responsible for the acts and omissions of their
  agents
• Health care providers and insurance carriers must
  work with their agents to remove technical and
  administrative barriers

25
eBill Agent Identification

• 28 TAC 124.2(n)(1) requires insurance carriers to
  provide TDI-DWC contact information for medical
  bill processing
• Some health care providers have reported that
  securing accurate information from insurance
  carriers and eBill agents is difficult
• The use of different Payer IDs has complicated
  the submission of eBills to the correct insurance
  carrier or their agent

26
Waivers

• Most of the current approved waivers are for
  technical issues and for a limited period of time
• All requests for extensions or additional waivers
  will be reviewed closely
• Requestors must provide
• Documentation of estimates,
• Verification of negotiations with existing eBill
  agents, and
• Other documentation that shows an unreasonable
  financial burden

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Open Discussion
skip navingation

• 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.