Healthcare Payment & Remittance Medical Banking - Best Practices. Art Conklin, Director of FirstProxy and Electronic Payment Services

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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 2

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 3

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 4

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. 5

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

7 The Standard Electronic Healthcare Payment Model Clearinghouses process 835 from Payer to Provider s Payer s bank processes EFT to Provider s 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. 7

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

9 Combining the Electronic Healthcare Payment s 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 9

10 Combining the Electronic Healthcare Payment s 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 10

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

12 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. 12

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 plan s payment responsibility. 13

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. 14

15 15 Appendices

16 Traditional Electronic Payment Workflow ERA/EFT Process Payer Gateway data translator (ANSI 835), ANSI edits connectivity Payer claims receipt Claims adjudication Accounts Payable ERA preparation Payer Gateway data translator (ANSI 835), ANSI edits connectivity Clearinghouse batching, consolidation and/or splitting logic Funds transfer Payer banking interface Payer Gateway data translator (ANSI 835), ANSI edits connectivity Provider claims submission Provider Accounts Receivable Reconciliation Manual posting PMS posting software Provider s proprietary software posting Provider bank Online EPP ERA preparation Banking institution EFT transaction creation and routing Clearinghouse batching, consolidation and/or splitting logic Network Payer Gateway data translator (ANSI 835), ANSI edits connectivity 16

17 Healthcare Account Debit Flow POS Technology Payer Gateway data translator (eligibility/benefit verification ANSI 270/271) edits connectivity Eligibility / benefit plan Enrollment / plan and fund set-up Payer Gateway data translator (ANSI 835), ANSI edits connectivity Payer banking interface Payer Gateway data translator (eligibility/benefit verification ANSI 270/271) edits connectivity Financial debt Provider bank Funds transfer Funds transfer Banking institution EFT transaction creation and routing Plan Sponsor Gateway data translator (ANSI 834), ANSI edits connectivity Plan Sponsor Fund Plan Sponsor Gateway data translator (ANSI 834), ANSI edits connectivity Provider office POS (card swipe) device ERA = Electronic Remittance Advice 17

18 Summary ProxyMed is the nation s 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 18

19 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 19

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