What HIPAA Covered Entities Can Learn From Property

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What HIPAA Covered Entities Can Learn From
Property Casualty eBillings End-to-End
Revenue Cycle Workflow!
Sherry Wilson, Jopari Solutions, Inc. Tina
Greene, Mitchell International Tammy Banks, Optum

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Topics

• Overview HIPAA Covered Non-Covered Entities
• Objective of Property Casualty (PC)
  Initiatives
• Top 10 Business Needs to Address in Order to
  Obtain Maximum ROI
• PC End-to-End Workflow ROI
• One workflow for all lines of healthcare
  business!
• Jopari Solutions, Inc.
• 5 Year ROI Study

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HIPAA Covered vs Non-Covered Entities -
Comparison

• PC includes workers compensation and auto
• Legal system vs. a medical system
• Subject to State vs. Federal Regulations
• Non-covered entityexempt from HIPAA
• Subscriber Employer vs. Patient
• Bill vs. Claim
• eBill electronic billing, attachment,
  acknowledgment and payment process for PC
• Compensability Determination vs. Eligibility
  of Benefits

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HIPAA Covered vs Non-Covered Entities -
Comparison

• Again remember legal system vs. medical system
• Heavy reliance on documentation for determining
• Compensability
• Disability
• Medical necessity plus additional state reporting
  requirements J1 Doctors First Report of
  Injury J2 Supplemental Medical Report J3
  Medical Permanent Impairment Report J4 Medical
  Legal Report J5 Vocational Report J6 Work
  Status Report J7 Consultation
  Report J8 Permanent Disability Report J9
  Itemized Statement

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HIPAA Covered vs Non-Covered Entities -
Similarities

• PC providers are the same providers that process
  government and commercial claims today
• Uses the same HIPAA transactions and code sets
  that are used for government and or
  commercial claims processing
• Collaborates with the same national standard
  setting organizations
• Many states include same operating rules in their
  regulations to gain administrative simplification

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Moving Toward One Automated End-to-End Workflow
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Objectives of eBill Initiatives

• Leverage existing solutions already in use today
  by covered entities
• same technology platforms
• same connectivity
• same process workflows
• same transactions and code sets
• Establish standard end-to-end workflow business
  rules
• Automate and streamline the standard end-to-end
  workflow process
• Eliminate unnecessary process steps and paper
• Realize ROI

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Objective of eBill Initiatives

• Alignment with current standards
• International Association of Industrial
  Accidents, Boards and Commissions (IAIABC)
• Align states with national standards vs. 50 state
  proprietary HIPAA regulations
• IAIABC Model Rule (endorsed by AMA)
• IAIABC National Workers Compensation Electronic
  Medical Billing and Payment Companion
  Guides (X12 collaboration)

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Objective of eBill Initiatives

• Alignment with current standards
• Industry collaboration with national standard
  organizations, including ASC X12, CAQH CORE,
  IAIABC, NCPDP, NUBC, NUCC, HL7 and others
• Address unique business requirements
• Incorporate use of the HIPAA transaction and code
  sets
• Advocate for consistent requirements across
  states
• Collaborate with professional associations, such
  as AHA, AMA, Cooperative Exchange, WEDI and
  others

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Automated End-to-End Workflow for All Lines of
Business
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Realize Maximum ROI by Solving the Top 10
Business Needs

• State Reform-reduce cost/increase data integrity
• Automate claim and attachment processing
• Increase clean claim first time submission
  rates
• Apply upfront business validation edits
• Audit trail at every touch point
• Reduce manual payer payment status inquires
• Proactively identify claim types to increase
  processing efficiencies 
• Decrease accounts receivable days (A/R)
• Shorten the revenue cycle management time to
  payment
• Align, as appropriate, with national
• standards (operating rules/EFT)

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Solving Those Business Needs

• Address business needs in isolation,
• does not bring ROI
  
• Mandating one EDI transaction does not
  resolvethe complete business issue
• Each business need is related to another only
  an end-to-end solution that addresses
  all/majority of business needs will result in
  maximum ROI
• If solve for one need, another business need
  negates ROI
• All stakeholder perspectives and buy in are
  required to ensure adoption
• Without an end-to-end workflow solution there is
  no ROI

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Solving Those Business Needs

• Business Need (example)
• Virtually all claims require mailing and faxing
  of supporting documentation/attachments
• Cost to send/receive, handle and match paper
  documentation is unsustainable
• What would be your solution?
• Would it be to implement the ASC X12 275
  Standard Transaction?

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Solving Those Business Needs

• Those of you who said yesso did the PC
  industry
• BUTdoes it address
• Reduce payer chasing/provider calls
• Ensure claim and supporting documentation is
  received by payer
• Confirm what supporting documentation is needed
• Address unsolicited attachments
• Address incomplete/missing supporting
  documentation
• Address rework on a claim without required
  supporting documentation
• AND SO ON

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PC Industry started with the basics

• Alignment and adoption of the HIPAA Standard
  Transactions
• Automate Claims
• ASCX12 N v5010 837 Health Care Claim
  (Professional, Institutional and Dental)
• NCPDP Telecommunication Standard Implementation
  Guide D.0
• NCPDP Batch Standard Implementation Guide 1.2
• Automate Electronic Remittance Advices
• ASCX12/005010X221A1 Health Care Claim Payment
  Advice (835)
• Alignment and adoption of the HIPAA Code Sets,
  including
• ICD-9-CM, AMA CPT, Standardized Reason and Remark
  Codes (CARCs RARCs)
• Require payers to move from proprietary reason
  and remarks to national reason and remark code
  set
• Alignment with HIPAA Privacy Security
  Regulations
• Alignment with CAQH CORE Operating Rules
  (ERA/EFT)
• Same foundation mandated by HIPAA for commercial
  and government

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Layered on.

• Attachment and Acknowledgment Transactions
• Not currently mandated under HIPAA, but found to
  be critical to solving for business needs and ROI
• Adopted Attachment Solution
• ASC X12N/005010X210 Additional Information to
  Support Health Care Claim (275)
• Other existing flexible technology solutions
• Flexible formats-existing solutions-clinical
  information
• Over one million attachments being processed a
  month
• Jopari Solutions, Inc.
• Adopted Acknowledgment Solutions
• ASCX12/005010 TA1 Acknowledgment
• ASC X12C/005010X231A1 Implementation
  Acknowledgment (997/999)
• ASCX12N/005010X214 Health Care Claim
  Acknowledgment (277CA) 
• Transactions that go into the back hole, without
  acknowledgments, result cost timely intensive
  phone calls for payers and providers.

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Layering on.

• Front-End Edits
• Complete Bill (clean claim) requirements
• Syntactically edits same as commercial and
  governmental edits
• State specific eBill regulation edits
• National PC business requirement edits
• Attachment front-edit rules - Attachments
  requirements for specific procedure/services
  billed (unsolicited)
• Handling a claim and supporting documentation
  once
• brings true ROI for payers and providers!

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Layered on.

• Additional Transaction Edits and Process Rules
• Established Duplicate Claim, Appeal
  
• and Reconsideration Rules
• NUBC Workers Compensation Condition Codes
• Duplicate Claim Condition Code W2
• Appeal/Reconsideration Condition Codes W3, W4
• Adoption of related CAQH CORE Operating Rules
• Standardized Reasons and Remark Codes
• Adoption of ASCX12 Technical Type Report 2 (TR2)
• Defines national Workers Compensation CARC/RARC
  Usage Rules
• Require payers to move from proprietary reason
  and remarks to national reason and remark code
  sets
• Adoption of business scenario definitions in
  addition to PC specific scenarios to provide
  standardization of payer code usage
• Enables backend revenue cycle workflow automation
  

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Layered on

• Recognize variation in EDI Readiness - Low Tech
  to High Tech
• Claims Submission Solution
• Direct data entry to batch processing
• Attachment Solution - Allow flexibility for.
• Submission Methods Sending attachments via
  secure electronic fax, secure encrypted email or
  other secure electronic transmission using the
  prescribed format (275) or a mutually agreed upon
  format.
• Format Content Allow flexible formats based on
  Trading Partner Agreements (e.g., PDFs, TIFFs,
  C-CDA, Objects) to accommodate PMS, EMR and/or
  other administrative/clinical systems.
• Vendor Attachment Solutions Low Tech to High
  Tech
• Bar coded coversheets and automated, secure Fax
  servers
• Web Portal upload of single or batches PDF or
  TIF images,
• EDI using ASCX12N 275 attachment standard
  transaction
• EDI using other methods

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Solving Business Needs

• Adoption Education
• IAIABC Model Rule template created a national
  standard approach
• Some states enacted eBill regulations included or
  based on IAIABC Model Rule template
• Payers implemented
• Individual state mandates
• Voluntarily applied eBill across all states where
  conduct business regardless if mandate in place
• Made good business sense - drove ROI
• Vendors implemented in existing solutions
• Marketed existing solution for workers
  compensation and auto eBilling
• Made good business sense-one workflow solution
  all lines of business
• Providers have more incentive to engage when
  solutions are incorporated within their existing
  workflow clear ROI

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PC End-to-End Workflow ROI -5 Year Study

•  

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Example of State Estimated ROI

  State Metrics   ROI Estimated Results   Comments
Example State Reform California Hard administrative calculated savings 600 million year Payer state reporting mandateseBill Effective Date 2012Audit penalty timelinesAcknowledgments - Electronic Audit Trail
Example State Reform Texas Reduce paper intense process up to 60 Expects similar savings as California Payer state reporting mandateseBill Effective Date 2009Audit penalty timelinesAcknowledgments - Electronic Audit Trail
WC Reform Top Priority for States Group Health/CMS/other eBill State EDI ROI calculated savings - cost drivers for reform Increase state momentum over the past 3 years
State eBill Reported Benefits as of June 2013 (actual ROI TBD) State eBill Reported Benefits as of June 2013 (actual ROI TBD) State eBill Reported Benefits as of June 2013 (actual ROI TBD)
Improved integrity and accuracy of data collected by the state Improved integrity and accuracy of data collected by the state Improved integrity and accuracy of data collected by the state
Critical to medical cost containment analysis Critical to medical cost containment analysis Critical to medical cost containment analysis
Data integrity has had significant impact on the state efforts to contain medical costs, which constitutes 60 of claims cost nationwide Data integrity has had significant impact on the state efforts to contain medical costs, which constitutes 60 of claims cost nationwide Data integrity has had significant impact on the state efforts to contain medical costs, which constitutes 60 of claims cost nationwide
eBill regulations supports quality/best practice analysis states are undertaking eBill regulations supports quality/best practice analysis states are undertaking eBill regulations supports quality/best practice analysis states are undertaking
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Provider Reported ROI
Metrics(Paper vs. eBill)1 National Occ. Health Service 2 CA based Ortho Practice CA based Billing Service CA based Small Practice
First Time Acceptance 70 to 90 50 to 83 68 to 88 40 to 84
Resubmission Rate 20 to 3 40 to 8 25 to 5 50 to15
Revenue Cycle Improvements DAR 80 to 45 Over 120 35 to 6 DAR 93 to 42 Over 120 53 to 15 DAR 73 to 38 Over 120 57 to 22 DAR 75 to 39 Over 120 62 to 24
Payment Cycle 45 to 19 days 63 to 27 days 58 to 31 days 67 to 28 days
Reduction Payer Status Calls 83 58 39 53
Notes 1. These are survey sample results from several practices that have been engaged in eBilling for 1 to 5 years submitting to varies numbers on payers. 2. Source Jopari Solutions, Inc., Property Casualty Electronic Medical Bill (eBill) White Paper - 5 Year Industry Progress Report, published June 25, 2013. Notes 1. These are survey sample results from several practices that have been engaged in eBilling for 1 to 5 years submitting to varies numbers on payers. 2. Source Jopari Solutions, Inc., Property Casualty Electronic Medical Bill (eBill) White Paper - 5 Year Industry Progress Report, published June 25, 2013. Notes 1. These are survey sample results from several practices that have been engaged in eBilling for 1 to 5 years submitting to varies numbers on payers. 2. Source Jopari Solutions, Inc., Property Casualty Electronic Medical Bill (eBill) White Paper - 5 Year Industry Progress Report, published June 25, 2013. Notes 1. These are survey sample results from several practices that have been engaged in eBilling for 1 to 5 years submitting to varies numbers on payers. 2. Source Jopari Solutions, Inc., Property Casualty Electronic Medical Bill (eBill) White Paper - 5 Year Industry Progress Report, published June 25, 2013. Notes 1. These are survey sample results from several practices that have been engaged in eBilling for 1 to 5 years submitting to varies numbers on payers. 2. Source Jopari Solutions, Inc., Property Casualty Electronic Medical Bill (eBill) White Paper - 5 Year Industry Progress Report, published June 25, 2013.
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Average Payer Reported ROI
Metrics (paper vs. eBill)   Average Payer ROI Reported Results Reported Drivers
Clean Claims First Time Submission Rates 63 increase Complete Clean Claim RulesFront-End Edits Attachments sent with Claim Acknowledgments
Duplicate Claims Submission 70 reduction Front-End EditsWC NUBC Condition Codes W2Acknowledgments
Appeal/Reconsiderations 45 reduction Front-End EditsAcknowledgments Standard ERA Format CARC/RARC Codes/Proprietary
Payment Status Inquires 64 reduction Front-End EditsAcknowledgments Standard ERA Format CARC RARC Codes/Proprietary ASCX12 TR2 WC CARC/RARC Usage Rules
Payment/Remittance Cycle 60 -100 days to14 Days Automated End-to-End Business WorkflowFront-End EditsAcknowledgments
Overall Reduction 70 reduction Automation End-to-End Business Workflow
Triage Time Sensitive Claims Document Processing 18 to 35 days to less than 2 days Mitigates Audit Penalties NUBC Condition Code EditsAttachment Edit RulesAcknowledgments - Audit Trail - Triage
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Regional Healthcare Provider ROI

• 6 sites in San Diego County
• 17 Physicians, 6 Physician Assistants 18.4 FTEs
• 110,000 Patient Visits per year
• 43 Workers Compensation
• 47,744 visits
• 13,262 cases
• 31 Pre-Employment Services
• 33,973 visits
• 4,000 active employers
• 26 Commercial
• 28,283 visits

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Cost Savings

• Due to Less
• ?Phone Calls
• ?Faxing
• ?Chart Pulls
• ?Mailings
• ?Manual Billing

• Decreased FTE Allocations
• Patient Service Rep 2.12 FTEs
• Medical Assistant 2.35 FTEs
• HIM 3.17 FTEs
• Specialty Care Case Mgmt. 1.08 FTEs
• Billing Rep 3.88 FTEs
• Authorization Rep 2.00 FTEs
• Total Reduction 14.60 FTEs

• FTE Salary and Benefits Saving 760,705 per year
• Workflow Automation Cost Savings 276,142 per
  year
• Net Cost Savings 484,563 per year
• Other expenses (paper, stamps, envelopes,
  etc.) not included

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Outcomes
2010 2011 2012 2013 2014
Visits (Occ. Health) 80,406 84,193 87,887 101,965 110,000
Reduction in FTEs 6.71 1.97 2.00 2.00 1.89
Days in AR 68 62 54 50 46
Collection Rate 84 85 86 86 91
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Compliance Landscape - 2009
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Regulatory Compliance Landscape 2014

Legislation
Activity
No Activity
EFT Required



Pending
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Today eBill Processing inAll 50 States
Voluntary adoption due to ROI - not state mandates
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One Workflow for All Lines of Healthcare Business

• EDI adoption has been an evolution
• Healthcare 18 years
• WC less than seven years
• Share many of the same stakeholders
• Share the same costs, issues needs for ROI
• Share a same common administration simplification
  goal
• One automated workflow across all lines of
  healthcare business
• Opportunity to leverage existing IT investments
  to achieve this goal

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One Workflow for All Lines of Healthcare Business

• National Market place demand already exists
• EDI Highway already built
• Industry connectivity resources already engaged
  in PC claims and attachment processing
• Vendors implemented in existing solutions
• Providers and payers can use same automated
  workflow they use today for commercial
  government claim processing
• Ability to leverage your existing IT investment
  to expand your business applications to include
  PC

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One Workflow for All Lines of Healthcare Business

• We need your help with stakeholder engagement!
• To achieve increased stakeholder engagement, as
  an Industry we must
• Collaborate
• Educate
• Standardized Connectivity
• Align with Standards and Operating Rules,
• as appropriate
• Take action today
• Sign up for the WEDI PC WG
• Networking stakeholders who do PC business
• Many state regulators engaged
• Discuss workflow automation challenges,
  opportunities and identify solutions using same
  technology

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• WEDI Property Casualty
• eBill Educational References
• White Papers
• Property Casualty eBill Business Requirements
  and Best Practices White Paper
• Property Casualty Code Value Usage Guidelines
  for Health Care Payment
• White Paper
• Property Casualty National Council for
  Prescription Drug Programs, (NCPDP)
• Business Requirements White Paper
• ICD-10
• WEDI Statement to NCVHS on Standards Regarding
  ICD-10 Implementation Beyond Covered Entities on
  February 19, 2014
• WEDI PowerPoint
• States aligning with the CMS ICD-10 requirements
• Other
• Summary eBill State Business Rules and
  Regulations

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Join today! PC eBill SWG

• Joining a workgroup is easy
• Sign in at www.wedi.org on the WEDI website
• Select My Profile
  
• Subscribe to the listserv that corresponds with
  each workgroup that youd
• like to join or contact Sam Holvey at
  202-618-8803, sholvey_at_wedi.org
• Share with your connectivity partners!

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Questions