HIPAA

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HIPAA EDI OUR EXPERIENCE
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BACKGROUND UWHC

• UWHC is a 500 bed complex academic medical
  center.
• gt 600,000 ambulatory encounters and 20,000
  admissions annually
• Siemans Invision mainframe HIS platform
• Cirius claims scrubber which processes the 837
  and 835 transactions.

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TOPICS

• What transactions have we implemented?
• What is working? Success stories along with
  goals for making these even better.
• What are the road blocks?
• What transactions havent we implemented and why
  not?

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837 Claims

• 95 of our primary claims are submitted in the
  compliant 837 format.
• Direct connections to 21 payers.
• 9 of our claims go to 1 clearinghouse
• Paper claims mostly to workers comp and/or small
  volume payers.

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837 Road Block

• Only two payers have allowed us to send secondary
  or COB claims in the 837 file. Until this
  happens with all payers, a significant amount of
  manpower and cost will go into billing secondary
  or tertiary claim.

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Payer response to the 837

• All payers give us at least a 997
  acknowledgement.
• The clearinghouse provides us with a proprietary
  file that includes acknowledgments from some of
  the payers.
• Several payers are giving us an electronic
  acknowledgment file with detail information. We
  are uploading these responses to the main frame
  account.

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835 - ERA

• We are receiving an 835 from 14 payers
• This represents about 40 of our cash posting
  volume
• Six of the 14 payers send funds through
  electronic funds transfer (EFT)

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ELECTRONIC FUNDS TRANSFER (EFT)

• The advantage of this for us is that the funds
  and the 835 arrive simultaneously in most cases.
• Without EFT, you must either hold your 835 file
  or post it and inform your general accounting
  department of the remits that have been posted
  without cash received.
• EFT saves the cost of printing and mailing checks
  so why are payers not making this change?

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POSITIVE ASPECTS OF THE 835

• We have reduced cashiering staff by 3 FTE
• Prior to the 835, some of our larger payers were
  taking the entire department 1-2 days to break
  out and key the weekly remit from that payer.
• The 835 process for cashiering is now a process
  of comparing control sheets to actual cash
  postings and verifying receipt of check.

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Automation with the 835

• The payment is posted to the account.
• Secondary bills and EOBs are produced within the
  835 process.
• Contractual allowances taken at time of billing
  are compared and corrected if necessary to the
  contractual allowances taken on the remit.
• Balances are identified and transferred to the
  next payer or patient, whichever is applicable.

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835 - Problems

• The poorly defined ansi codes do not cover all of
  the scenarios that the proprietary codes covered.
• The lack of standardization in how the ansi codes
  are used among payers eliminates using these
  codes for any type of automated follow up.
• Some payers may send 1 file for multiple checks.
  This creates a balancing nightmare. (UWHC does
  not have this happening currently)
• Payers that do not use EFT are decreasing the
  efficiency of this transaction.

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276/277 Claims Status Inquiry
WANTED! PAYERS THAT WILL STEP UP TO THE PLATE
AND TEST THIS TRANSACTION
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276 (cont.)

• We have tested the 276 with 4 payers.
• Only one payer has indicated they can take this
  transaction and respond with a 277, however, they
  are having system issues at the current time.
• This is a transaction we hope to gain
  considerable benefit from.

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276 - goals

• Send 276 transactions individually (real time) or
  in batches
• Define when we would like to send off a 276
  transaction.
• Upload the response from the payer
• Generate statements based on certain responses
• Establish work flow for follow up staff based on
  responses in the 277.
• Reduce the time follow up staff sit on the phone
  with insurance companies.

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271/272 Eligibility

• We currently use an outside vendor for batch and
  individual eligibility queries for 3 payers.
• Most other payers are telling us they are not
  ready for this transaction.

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271 (cont.)

• Most payer responses to 271 and 276 transactions
  is to provide a website where we can check
  eligibility and claim status.
• This response requires nearly the same amount of
  resources as making phone calls to the payer and
  does not provide administrative simplification.

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Summary

• The intent of HIPAA is good but progress is
  painfully slow.
• Business office staff do not make patients feel
  better. We need to push forward with the
  transactions and eliminate the road blocks. This
  will reduce costs which is a benefit to payers
  and providers.