HIPAA Summit

1
HIPAA Summit

• EDI Enrollment
• A Manual Process
• in the EDI Chain
• Marcallee Jackson
• ProxyMed, Inc.
• mjackson_at_proxymed.com

2
Todays Objectives

• Review the difference between Trading Partner
  Agreements and EDI Enrollment Forms
• Review the common EDI enrollment processes for
  clearinghouses (CHs) today
• Discuss trends and their impact on the industry
• Identify key requirements of the agreements
• Discuss proposed alternatives to traditional
  processes

3
Two Agreements

• Trading partner agreements
• Most commonly entered into by two entities
  directly exchanging transactions
• Defines the rules of engagement for each trading
  partner
• May or may not require signature
• EDI Enrollment
• Serves as the providers request to exchange
  transactions with the payer
• Contractually binds the provider and payer to
  certain requirements and conditions
• Almost always requires a provider or officers
  signature

4
Common Requirements

• Examining 1200 payers on a CH payer list
• 27 require enrollment 73 of payers do not
• Of the number that do, 78 are government plans
  and 22 commercial
• Commercial payers requiring enrollment make up
  less than 6 of payers overall
• Depending on a number of factors, the enrollment
  process takes 2 - 12 weeks to complete
• For claims, on average, a provider sending all
  payer to a CH will complete 4 separate
  enrollment forms along with the CH contracts and
  forms

5
Common Requirements

• As much as 20 of CH FTEs are dedicated to
  facilitating payer EDI enrollment
• Forms are obtained from payers, distributed to
  providers and the CH most often supports the
  provider in completing the forms
• CHs normally track enrollment status and make
  calls to payers as necessary
• When errors occur, the CH must identify and
  resolve them
• Even when the process works well it is expensive
  and drains CH resources

6
Trends

• Commercial payers are beginning to implement EDI
  enrollment
• As health plans change intermediaries, business
  associates and systems, some are requiring
  re-enrollment
• CHs mergers and consolidations may require
  submitters to re-enroll under new submitter
  numbers
• As submitters migrate from direct submission to
  the CH, or visa verse, a requirement for
  re-enrollment is likely
• Often, new transactions, such as ERA, will
  require that existing submitters complete new
  forms

7
Impact

• Increased administrative costs to everyone in the
  chain
• Places an undo burden on the CH
• Complicates the EDI process
• Implementation timeline is extended
• Providers perform selective implementation
• Results in lower EDI volume

8
Key Requirements

• Based on a cursory review of EDI enrollment
  agreements
• Assignment of CH as agent
• Agreement to notify payer of a change in agent
• Agreement to meet payer billing requirements
• Agreement to exchange accurate and true data
• Agreement to maintain source documents
• Agreement to permit audit
• Agreement to obtain any required consent

9
Key Requirements

• Continued . . .
• Agreement to use unique identifiers
• Agreement to meet testing requirements
• Agreement to correct errors
• Agreement to report problems/failed transmission
• Agreement to protect privacy and confidentiality
• Mandatory arbitration
• Term
• Contract termination

10
Key Requirements

• Continued . . .
• Agreement to hold the payer harmless
• Notice of the plan contractors obligation to
  provide no cost option
• Provider listing with ID numbers

11
Alternatives

• Universal language to be included in all service
  agreements between providers and CH's that
  address each requirement described here.
• Provider assigns CH power of attorney for EDI
  enrollment. Example language
• Provider shall comply with ltCHgt procedures to
  secure any authorizations then required by ltCHgt,
  applicable law, or industry practice in
  connection with the lttransaction servicesgt.
  Provider hereby appoints ltCHgt as its
  attorney-in-fact for the limited purpose
  submitting Providers Transactions and/or signing
  paper Transactions on Providers behalf to
  third-party payers or processors, including, but
  not limited to, commercial insurers, Medicare,
  Medicaid and government agencies, and, where
  appropriate, agencies or carriers covering
  work-related accident or illness benefits, where
  Providers signature is required for processing
  or adjudication.

12
Alternatives

• Continued . . .
• One form completed and signed, used for all
  payers
• ANSI X-12 274 Provider Enrollment transaction

13
Contributors

• Cooperative Exchange Association
• AFEHCT