Diving Deeper: How a Multi-Payer Company Addressed Four Overlooked Areas of Inefficiency in Claims Payment and Data Delivery

Transcription

1 Diving Deeper: How a Multi-Payer Company Addressed Four Overlooked Areas of Inefficiency in Claims Payment and Data Delivery Eileen Lee, Director of Web Technologies

2 Who is Zelis Payments? Zelis Payments Zelis Payments is a leading payment and data facilitator designed exclusively for healthcare which is exclusively integrated into core claim payment platforms ensuring efficient workflow for the Payer. Our Objective Our objective is to provide the most innovative, comprehensive and efficient payment management solutions at one destination. Our Expertise Our expertise includes provider payments and enrollment, integrated payment technology, fully scalable operational support and ERA/835 compliance. Our Results In 2016, Zelis is expected to exceed epayment delivery to over 250,000 healthcare providers from 125+ Payer clients Members of: 2

3 About Me 18 years in Payer Side Healthcare IT EDI Solution Architecture for 10 years Director of Web Technologies for Zelis Payments Former Owner/President of Blue Cheetah Software Former Web Development Lead for Managed Care of America Former Development Analyst for Accenture/Andersen Consulting Graduate Rice University Eileen Lee Director, Web Technologies 3

4 How We Looked at epayments There is More Below the Surface Achieve Compliance Cut Overhead Costs Reduce Cycle Time Enable Re-Association For us, it was just the tip of iceberg. We saw an opportunity to deliver more value to Payers and Providers. 4

5 Delivering Operational Efficiencies... Below the Water Line Our Solutions Areas of Inefficiency 5

6 OUT-OF-SYSTEM RECONCILIATION: PAYERS

7 Out-of-System Reconciliation: Payer Payer Partner s Core System Create Payment Payment File (Outbound Job) Payment & Remittance Data Process Paper Payment & Remittance Process epayment & Remittance Check Printer epayment Vendor Transaction Report Transaction Report DB Manual or Third- Party Reconciliation Manual Adjustments 7

8 Our Solution: Proprietary Integration 8

9 Our Solutions: Proprietary Integration The Zelis Payments integration results in seamless workflow throughout the payment process. Payer Partner s Core System Create Payment Pre-Pass (Outbound Job) Payment & Payee Data Payment and Payee Evaluation Pre-Pass (Inbound Job) Confirm Payment & Payees DB Payment File (Outbound Job) Payment & Remittance Data Process Payment & Remittance Payment Status Update Payment Status 9

10 Integrated Reporting = Greater Accuracy Payer Partner s Core System Create Payment DB Pre-Pass (Outbound Job) Pre-Pass (Inbound Job) Payment & Payee Data epayment Status for All epayment Types epayments will Auto Balance Confirm Payment within & the Payees System Auto-835 Balancing & Compliance Validation Supports Positive Pay Payment and Payee Evaluation Representatives have Access Payment & to Remittance Up-to-Date Data Transaction Data Payment File (Outbound Job) Process Payment & Remittance Payment Status Update Payment Status 10

11 The Result Easily and accurately identify EFT transactions Eliminates the need for back office updating Mitigates banking issues Prevents misused check numbers Without the integrated capability, I'm pretty sure that we would have to hire half an army to reconcile the information back into our system if we had to do it manually. - CFO, Third Party Administrator Copyright All Rights Reserved 11

12 OUT-OF-SYSTEM RECONCILIATION: PROVIDERS

13 Lock Box epayment Process Scanned PROVIDER PAYMENT CENTER PAYER LOCKBOX Scanned via OCR MANUALLY Payment and data are manually reconciled at Provider. PROVIDER DATA CENTER 13

14 Traditional epayment Process ACH-CCD+ With TRN PROVIDER S BANK Payment Data with TRN PROVIDER SYSTEM PAYER Digitized E-PAYMENT VENDOR clean data Payment is auto reconciled using TRN Data output to provider is only as good as data in - if the EOP data is check-level only it will not be as detailed as the data pulled directly from the Payer s core system 14

15 Zelis Payments Virtual Reimbursement Account Payment & Data ACH-CCD+ With TRN PROVIDER S BANK Payment Data with TRN Re-associates Automatically PAYER DIRECT DATA LOAD CAGC CARC RARC ZELIS SYSTEM Zelis integrated within the core system 835 Aggregation Aggregated Data with TRN placed in a SINGLE 835 More detailed and accurate 835 data PROVIDER SYSTEM Data placed into a single 835 for the Payer Providers only have to handle 1 file for all payers 15

16 Clean, Balanced and Detailed 835s NON-Zelis 5010/835 ZELIS DETAILED 5010/835 Adjustment CAGC CARC RARC Description A. $50 $25 PR PR 1 Deductible Deductible A. $25 PR A2 B2 Non-PPO Deductible B. $60 OA 23 Other Adjustments B. $30 PI 40 Charges do not meet qualifications for emergent/urgent care. Note: refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. $30 PI 14 The date of birth follows the date of service 16

17 The Result Automatic re-association with 100% clean 835s and all payments Manages the processing of EFT and ERA delivery days sooner than even lock box delivery Facilitates the routing and placement of payment and remittance data to specific locations within the healthcare system Eliminates manual entry and rework required with either paper check or OCR created 835s Our payments and 835s have reconciled correctly to the penny. The automation has eliminated hours of work for our staff. - Director of Cash Posting & Revenue Management Healthcare System Copyright All Rights Reserved 17

18 INABILITY TO RE-ASSOCIATE VIRTUAL CARDS

19 Why Would a Provider Take a Virtual Card over a ACH? Doesn t want to wait for a check. Payer lacks volume. Virtual Cards speed payment without the need to manage banking and data connections. Copyright All Rights Reserved 19

20 The Problem: Virtual Cards Payments are Inefficient and Not Compliant Re-association Trace Numbers not part of the data stream What that means for the provider: Manual re-association of the EFT and ERA and extensive time delays between receipt of the EFT and ERA Require manual entry and reconciliation What that means for the provider: Each card = 30 to 34 keystrokes per transaction Manual reconciliation required Copyright All Rights Reserved 20

21 Straight-Through Processing via Direct ACH or MasterCard Multiple payers managed via one account Simple workflow: automatic reconciliation and re-association Clean, compliant 835s and payments CAQH CORE certified Flexible, reasonable fees 21

22 MULTI-PAYER DATA 22

23 The Problem Providers who take ACH/835 do it traditionally for Payers who are their higher volume Payers It does not make sense for a Provider to load a Payer s 835 data file for a small number of payments Our Solution Zelis Payments, due to our Aggregation, has a better chance of getting a Provider to take our ACH/835 because we represent MANY Payers Zelis Payments becomes a single source for multiple Payers Copyright All Rights Reserved 23

24 What does this Mean to Providers? Zelis Payments creates the Payment and Data BRIDGE between Non-BUCA Payers and all Providers.. Aggregation of these Payers creates a SINGLE COHESIVE RELATIONSHIP for Providers, versus the traditional management of hundreds of individual Payers Zelis Payments is a single source BRIDGE between a Provider and many Payers. 24

25 Zelis Payments Manages Multiple Connections WITHOUT ZELIS >150 Payers >150 separate connections TPA WITH ZELIS HEALTH SYSTEM >150 Payers TPA ZELIS SYSTEM ONE connection HEALTH SYSTEM 25

26 Solution: Aggregation Without Aggregation With Combination of 835 s With more 835 activity due to larger 825, Provider is more likely to accept the file feed. Payer ID X 835 Payer ID X One 835 Payer ID Y 835 Payer ID Y 835 Payer ID Z 835 Payer ID Z This One-to-Many Relationship Simplifies Data Handling for Providers. 27

27 PROVIDER-LEVEL DELIVERY WITHIN LARGE HEALTH SYSTEMS 28

28 The Problem Within large healthcare systems, paper check payments may be delivered directly to the Provider who submitted the claim, when they should be routed to a different NPI within the system This misrouting results in additional work, lengthy reconciliation processes and disruption in cash flow Our Solution Location Routing Hierarchy Management Copyright All Rights Reserved 29

29 Why Location Routing? Dr. Brown and Dr. Smith are both providers in XYZ Health System. Dr. Brown Neurologist 16 Union St. Dr. Smith Rheumatologist 3 Reid Road TIN: PO Box:

30 Why Location Routing? Dr. Smith s payment and data could mistakenly be applied to Dr. Brown. WEEKS LATER Dr. Brown Dr. Smith Dr. Smith WEEKS LATER Dr. Brown Dr. Smith 31

31 Zelis Location Routing Dr. Smith TIN NPI Provider Name Address Payer Tina Smith 3 Reid Road 156 Payer NULL Move Free Rheumatology P.O. Box Payer Tina M. Smith P.O. Box Location Code High ranking matches are automatically linked to existing provider record. 32

32 Zelis Location Routing Dr. Smith TIN NPI Provider Name Address Payer Tina Smith 3 Reid Road 156 Payer NULL Move Free Rheumatology P.O. Box Payer Tina M. Smith P.O. Box Location Code Low ranking matches are routed to verification team for manual resolution. 33

33 Why Hierarchy Management? ACME Health System Corporate TIN Payment Center A Payment Center B Hospital West Payment Provider and data may need to be re-routed/transferred within the system. This process could take weeks and delay reconciliation or balance billing Outpatient Surgical Center Hospital North Urgent Care Diagnostic and Imaging Center Urgent Care Urgent Care 34

34 Zelis Hierarchy Management Summary Corporate Payment Center B Payment Center A Hospital West Hospital North Women s Care Affiliate Family Practice Affiliate Diagnostic & Imaging Ctr. Urgent Care Outpatient Surgery Ctr. Urgent Care Payments are routed to preferred levels within the hierarchy, which helps to speed reconciliation and revenue cycle process ISP- ER Urgent Care 35

35 Dedicated to Improving Efficiency Ground-breaking study to understand a healthcare provider s fully-loaded cost of processing benefit payments and the impact electronic payments on the revenue cycle Why the study is important: In the face of declining reimbursement and increasing quality expectations, the revenue cycle must evolve to more effectively manage account receivables This study will estimate potential cost savings from replacement of manual transactions with electronic methods and attempt to quantify the impact cash flow delays have on the revenue cycle Study Objectives: Calculate the fully-loaded transaction-based cost incurred when processing various types of electronic and manual benefit payments and explanation of benefits transactions by gaining an understanding of the allocation of time, resources and activities utilized for each transaction type Interested in participating? Contact Jase DuRard at (615) Calculate reimbursement revenue cycle for the various payment types. Understand the time discrepancy from payment submission to revenue receipt. Identifying cash flow delays will highlight the value of improved on-time payment 36

36 Thank You Copyright All Rights Reserved