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ERA Posting Improves Practice Efficiency
Jerrie K. Weith, FHFMA, CMPEChastity D. Werner, RHIT, CMPE, NCP
Anders Health Care Services Webinar SeriesMarch 19th, 2014
Learning Objectives
Background and benefits
Creating a plan
Set-up
The process
Reconciliation that works
Automation opportunities
Resources
Background & Benefits
Source: The Physician Billing Process: 12 Potholes to Avoid in the Road to Getting Paid, ed. 2, Walker-Keegan, Woodcock, Larch.
More efficient, saves time, saves money
Old process: opening mail, logging in payments, stamping checks for deposit, preparing the deposit and courier
EFT: payer directly transmits the funds it owes a medical practice to the medical practice’s bank account. ERA is forwarded to practice with payment details.
Background & Benefits
CAQH CORE 360: Uniform Use of CARCs and RARCs (835) Rule - Problem Addressed & Key Impact
Problem addressed by the rule:
Providers do not receive uniform code combinations for same or similar business scenarios from all health plans; as a result, are unable to automatically post claim payment adjustments and denials accurately and consistently
Focus on minimum business scenarios with maximum set of code combinations targeting 80% of major provider usage problems/high volume code combinations
Without business scenarios and maximum set of code combinations, there are over 800 RARCs, approximately 200 CARCs and 4 CAGCs resulting in thousands of possible code combinations for review by providers
Reference: www.caqh.org
Key impact:
Begins to address a significant industry challenge by addressing high-volume issues
Providers can more effectively use ERA data when definitions for claim payment adjustments or denials are consistent across all health plans, resulting in better revenue cycle and cash flow management
Providers can more effectively obtain payment from patients, more quickly generate cross-over claims to other payers, and reduce open accounts receivable
Requires more focus on the use of standard codes (not proprietary codes)
Background & Benefits
Reference: www.caqh.org
Background & Benefits
Payment Posting
46% 51%
• Transaction count of payer payments disbursed via EFT• 5% increase over 2 year period• PPACA mandate effective date 1/1/2014
Reference: InstaMed Trends in Healthcare Payments Annual Report: 2012
$300 billion is spent annually on manual and paper intensive processes to
disburse payments from payers to providers.
Background & Benefits
Increased efficiency!
Faster payments!
Increased time with patients!
Interface with clearinghouse
Direct via payer website or clearinghouse
Click icon to add picture
Reference: http://www.aetna.com/provider/medical/service_med/electronic_med/edi_calculator/EDI_Savings_Calc.html
Background & Benefits
Reference: http://www.ama-assn.org/resources/doc/psa/eft-getting-started.pdf
Case Study
Background & Benefits
FTEs 3
Hours designated to posting payments 1,456Rate $16.25Total $70,980
3 FTEs devote 70% of their time to posting payments/30% to following up on accounts• 2,080 x .70=1456
hours
Average wages $13 hour + benefits = $16.25
FTEs 1
Hours designated to posting payments 1,456Rate $16.25Total $23,660
Manual Posting
Electronic Posting
CREATING A PLAN
Creating a Plan
Current process• Steps taken• Physical storage versus electronic
Creating a Plan
Who’s involved• Internally• Externally
Magnum PI
Timeline
Test 1-2-3
Tweak
SET-UP
Set-Up
Perform payer analysis
Enroll with payers (direct or via
clearinghouse)
System set-uppayer profiles
Payer ProfilesSet-up according to
payerERA payer ID
Remittance libraryReason code set-up
Automation according to reason code
Create a path between practice & clearinghouse/payer
Set-Up
Clearinghouse• ERA/EFT set-up• Internal set-up
Set paths for communication
• Perform payer/ERA analysis
Payers• Direct ERA enrollment
More complex EFT enrollment
http://www.ama-assn.org/ama/pub/physician-resources/practice-management-center/health-insurer-payer-relations/payer-specific-information.page?
Set-Up
Payer profile• ERA Payer ID• Reason Code
Library• Remittance
Profile Library
Set-Up
Reason Code Library• Add code• Skip Adjustment Code• Transaction Detail Status
What are your numbers?
“On the fly”
Reason Code Library www.wpc-edi.com/reference/codelists/healthcare
Set-Up
Remittance Profile Library
Set-Up
Automation• Now or later?• Tasking by reason
Invalid ID - Front desk Medical necessity - Coding/billing
• Tasking by post date
THE PROCESS
Process
Utilize a clearinghouse
Download remit
Upload to system
Review and correct issues
Post to system
Process
System• Process
Import remittance Create a batch name
– Payer name_deposit date_amount Process date versus post date Reason codes again
RECONCILIATION THAT WORKS
Reconciliation That Works
Payment posting• Contractual • Non-contractual• Post all zero pays• Reconciliation
Click icon to add pictureReconciliation Process:1) Separate deposits2) One batch per deposit 3) Uniform batch description
(i.e. Anthem 03/19/2014 $34,584.03 )4) Match to bank deposits to system
(i.e. download bank report & system report to Excel then sort data accordingly)
AUTOMATION OPPORTUNITIES
Automation Opportunities
Real time edits• Task PMS claim edits• GIGO or • Clean claims out=$$$
Electronic transactions• 837-electronic claims• 835-remittance advice • 270/271-elibility benefit
inquiry and response• 276/277-claim status
inquiry and response
Automation Opportunities
100 claims per day X 20 days a month 2,000 claims
20% denial rate
2,000 claims X 20% = 400 claims
33% of denials are never recovered
400 X 33% = 132
132 X $100.00 (average reimbursement) = $13,200 monthly
Source: The Physician Billing Process: 12 Potholes to Avoid in the Road to Getting Paid, ed. 2, Walker-Keegan, Woodcock, Larch.
$158,400 annually
Resources
www.caqh.org
http://www.caqh.org/Host/CORE/EFT-ERA/EFT-ERA_Rules_Overview.pdf
www.availity.net
www.navinet.com
www.ama-assn.org• Payer policies• Toolkits
Anders Webinar Series
• Credentialing Doesn’t Have to be Hard!• June 18
• Effective Technology Will Elevate Your Practice• September 17
• 2015 – Here We Come!• November 19
http://anderscpa.com/webinar-series/
Questions
Anders Health Care Services
Anders Health Care Services optimizes staff, resources and revenue for hospitals and
physicians by offering solutions and direction to complex practice management issues.
We provide an integrated approach from the financial, operational, compliance and strategic
perspectives.
Anders Health Care Services
Jerrie K. Weith, FHFMA, CMPE
314-655-5558
Chastity D. Werner, RHIT, CMPE, NCP
314-655-5561
Anders Health Care Services
Brian McCook [email protected]
John McGuire [email protected]
Brian Meyers [email protected]
Jerrie Weith [email protected]
Chastity Werner [email protected]
314-655-5500
www.andershealthcare.com
