Welcome & Introductions WEDI P&C Co-Chairs Tammy Banks, Optum Cloud Tina Greene, Mitchell International Sherry Wilson, Jopari Solutions WEDI P&C Secretary Alicia Bell, Jopari Solutions
Electronification of Attachments Taking the Paper our of Healthcare Transaction Processing What you need to know about how attachments are being processed today Paper/Electronic/and future Learn the latest update on HL7 initiatives and join your colleagues in industry feedback regarding the upcoming Feb 16 NCVHS Attachment Testimony Moderator: Debra Strickland, Chair Cooperative Exchange Educational Committee, Xerox Speakers: Durwin Day, Co Chair HL7 Attachment, HCSC Debbie Meisner, Co Chair Attachment Collaboration Project (ACP HL7 WEDI and X12), Change Health Sherry Wilson, President Cooperative Exchange, National Clearinghouse Association, Jopari Solutions
Overview of Cooperative Exchange (CE) 26 clearinghouse member companies Represent over 95% of the clearinghouse industry Over 750,000 submitting provider organizations Maintain over 8,000 Payer connections 1000 plus HIT vendor connections Process over 4 plus billion claims annually Value of transactions over $1.1 Trillion Infrastructure framework supports BOTH administrative and clinical transactions
Our Members American Medical Association (AMA) Greenway Health PassportHealth Apex EDI GE Healthcare PracticeInsight ASC X12N Health-e-Web, Inc. RelayHealth Availity, LLC HDM Corp. The SSI Group AXIOM Systems, Inc. InMediata Trizetto Provider Solutions BancTec InstaMed Utah Health Information Exchange (UHIN) Cerner Jopari Solutions, Inc. WEX, Inc. ClaimRemedi Medical Electronic Attachments (MEA) WorkCompEDI ClinXdata NextGen Healthcare Xerox EDI Direct Dorado Systems OfficeAlly ZirMed Change Healthcare OptumInsight eprovider Solutions
Industry Attachments What types of services require Attachments (clinical documents) Claim payment Prior authorization Referrals Notifications Post Adjudicated Claims Common criteria for determining if the attachments are needed What are the rules we can put up front in the industry in order to support attachment exchange CPT range modifiers - i.e., surgical claim will require op report Payer specific rules
Getting Started WEDI/ASCX12/HL7 Attachments Collaboration Project (ACP) Guidance on Implementation of Attachments for Healthcare Transactions HL7 Documents HL7 CDA Quick Reference Guide HL7 Consolidated Clinical Document Architecture Release 2 (C-CDA R2) HL7 Clinical Documents for Payers Set 1 (CDP1) HL7 Digital Signatures and Delegation of Rights Release 1 ASC X12 Documents ASC X12N 277 Health Care Claim Request for Additional Information ASC X12N 275 Additional Information to Support a Health Care Claim or Encounter ASC X12N 278 Health Care Services Review Request for Review and Response ASC X12N 275 Additional Information to Support a Health Care Services Review ASC X12N 837 Health Care Claim: Professional (837-P) ASC X12N 837 Health Care Claim: Institutional (837-I) ASC X12N 837 Health Care Claim: Dental (837-D)
Building the Foundation
Relationship of Standards and IGs Consolidated CDA IG R2.1 (DSTU) CDP1 IG (DSTU) Future IGs Consolidated CDA R2 (DSTU) Attachments Work Group Supplemental Guide (Informative) ASC X12N 277/275 TR3 ASC X12N 278/275 TR3 CDA R2 RIM LOINC XML (W3C Standard)
Road to Attachments
How are Attachments Done Today? Paper process At the very basic level there are providers that prefer to do attachments via paper Electronic process EDI Stakeholders engaged in end-to-end workflow automation solutions based on different levels of EDI readiness
How the Industry is Using Paper Attachments Payer request via letter, Provider response paper Request : Payer will send a letter to the provider requesting specifically what he wants. Problems : Mail returned to the payer, no tracking of mail receipt (no audit trail), Results : Increased phone calls, manual handling, denying & then reprocessing claim, delay in adjudication Response : Provider will respond to the request via paper and send through the mail. Problems Lost in mail, No audit trail, Cost of mail, resource time, delay in revenue cycle, provider is uncertain of what is needed by payer Results : High cost for payer to consume large paper attachments and provider to send them. This is a time consuming, manual process and high cost option.
Issues Surrounding Paper Attachments Scenario: Payer requests information (paper, email, fax, phone) Payer Issues: Postage & mailing Returned mail Staffing Determine what is needed Mailing of request, dealing with response Increased phone calls due to provider not understanding request Increase in claim status claims Claims/Authorization denied as response wasn t received, resulting in reprocessing
Issues Surrounding Paper Attachments Provider Issues: Request isn t received, unaware request was to be received no tracking Negative impact to revenue cycle Staffing Need to determine the what, who, where Pull the response, review data to ensure appropriate information is sent (minimal necessary) Submission for reprocessing if request is denied as response isn t received by payer
Electronic Attachments Used Today Stakeholder Business Needs Automate end-to-end workflow processes across stakeholders to streamline administrative processes Decrease administrative cost associated with paper processing Absence of regulation has left the industry to develop processes that work for them because it makes good business sense There are a variety of electronic transmission methodologies used today based on stakeholder EDI readiness. There is a dependency on the flexibility of these various methods because they were developed and adapted by the needs of the various stakeholders. We cannot remove the flexibility during the process of regulating a standard
Infrastructure EDI Highway is Built Cooperative Exchange members are processing over 3 million attachment a month Financial Institutions Public Health Reference Labs PBM s Remits Lockbox Bio- Surveillance Reports Hospitals and Provider Offices Requests Results CE CLEARINGHOUSES Scripts History Health Plans Claims Claims Referrals Referrals Eligibility Claims Scripts Fill Notice Claims Payments Utilization Reports PHR Maint. Retail Pharmacy Minute Clinics Employers Consumers
How the Industry is using Electronic Attachments? Healthcare Lines of Business - Auto and Workers Compensation (2008) - Dental - Commercial - Government Attachment Applications - Claim Adjudication and Post Adjudication - Referral/Notification - Prior Authorization Attachment Supported Formats - Clearinghouses - Unstructured Attachments (MSWord, PDF, Plain Text, RTF, HTML,GIF,TIF,JPEG, PNG) - Structured Attachments ( C-CDA) Acknowledgments Consistent with the ARM TA1 999 277CA 824
How the Industry is using Electronic Attachments? Payer Requested Attachments - Solicited: ASCX12 277 Request for Additional Information - Unsolicited: Payer Attachment Front End Rules (80/20) CPT Range - Modifiers Complete Claim Claim and required attachment Convergence of administrative and clinical documentation Submission Methodologies - Flexible Attachment Solutions (Stakeholder EDI Readiness low tech to high tech) - Bar coded coversheets and automated, secure Fax server application - Secure email (Direct) - Web portal upload of single or batches - EDI using ASCX12 275 Envelope - EDI using HL7 CDA - EDI other application
Results Property Casualty Attachment Stakeholders ROI Experiences Jopari Solutions - 5 Year Case Study
Average Provider ROI Experiences Metrics (Paper over EDI) Transaction Report Type Specificity (PWK01/LOINCs) First Time Claim Submission Payment Cycle Improvement Payer Claim Status Calls Average Experience Expedites routing for triaging clinical as well as administrative resulting in faster payment Increase 75% over manual Manual 60 plus days, now 8 to 10 days 50% plus reduction Average 40 to 55% administrative cost savings associated with staff resource time. Comments Expedites Treatment Authorizations which impacts patient care Clear Understanding of the Payer Rules - Front End Edits Clean Claim Outcomes Acknowledgements- Immediate status, eliminates lost documentation
Average Payer Experience ROI Metrics Metrics (paper vs EDI) Clean Claims First Time Submission Rates Average Payer Reported Drivers ROI Metrics Results 63% increase Complete Clean Claim Rules includes Attachment Front End Edits 277CA + Acknowledgements Duplicate Claims Submission Appeal/ Reconsiderations Payment Status Inquires Payment/ Remittance Cycle 70% reduction Front End Edits WC NUBC Condition Codes=W2 45% reduction Front End Edits 277CA + Acknowledgments ASCX12 835 CARC RARC Codes Attachment specificity 64% reduction Front End Edits 277CA + Acknowledgments ASCX12 835 CARC RARC Codes Attachment specificity 60-100 days to 14 Automated End-to-End Business Workflow Days Front End Edits Acknowledgments Overall Reduction 70% reduction Automation End-to-End Business Workflow
Lessons Learned Flexible Attachment Solutions that leverage existing stakeholder IT investments and facilitates adoption Documentation Type specificity is critical to allow internal routing to expedite business processes ASCX12 837 PWK01 Report Type Codes LOINC Codes If not specific, manual intervention is required adding time and cost Acknowledgments - ROI Impact Impact overall administrative costs and time Provider knows immediate status of the claim Eliminates phones calls and black hole (duplicate submissions) Front End Clean Claim Edits Payer Attachment Rules Significant improvement in first time claim submission end-to-end workflow (75%) Need Flexible Transport Methodologies to accommodate different levels of stakeholder EDI readiness to facilitate adoption
Recommendation 1. Envelope Recommend ASCX12 275 and Allow Trading Partner Agreement for other methods 2. ASC X12N 277 Request for Additional Information 3. HL7 Consolidated CDA R2.1 - Similar to a TR3 Unstructured Document (mandate) Structured Document Types (optional support phased) 4. HL7 Supplemental Guide Created to use C-CDA R2.1 for Attachments 5. HL7 Clinical Documents for Payers Set 1 (Optional) 6. LOINC (subset HIPAA Panel) To identify Attachment Types and data content. 7. Acknowledgments (ARM) Adopt the ARM to acknowledge the transactions.
Open Discussion 1. What are you doing with Attachments today? 2. Do you have other recommendations for consideration?
Attachment Industry Resources Get Engaged HL7 http://www.hl7.org/ HL7-WEDI- ASCX12-APC Joint Project National Attachment Implementation Guide White Paper: www.wedi.org
Definitions Attachment AKA Clinical document (CD) Additional information needed to support a healthcare activity such as Claim review/payment, Post Adjudication Review Prior authorizations Care Management (Transition of Care, Clinical Decision) Referral and Notification. Unstructured Structured Undefined set of data elements that requires manual intervention to be usable Examples: MSWord, PDF, Plain Text, RTF, HTML, GIF, TIF, JPEG, PNG Defined set of data elements that are predictable and machine readable. Examples : C-CDA (HL7) Solicited Attachment Payer requested documentation for Attachments Unsolicited Attachment Provider initiated Attachment, sent without request. Provider initiated attachment based upon pre-established attachment rules (front end edits can be applied clean claim)