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Claim Attachmentsgrassroots efforts

W E D I S E S S I O N R E P L AY & U P D AT E S

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1Administrative Simplification: Where are we?

2Claim Attachments:We know the problem.

3Building a Business Case:Still learning the costs.

4Multi-Vendor Model:It takes a village.

5Moving Forward:Solving the top 5 challenges

Table of Contents

John Kelly, Principal Business Advisor

Sherry Wilson, EVP and CCO

speakers

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Polling Question 1

Is the lack of standards stopping your organization from investing in electronic claims attachment?

a) Yesb) Noc) Somewhatd) Don’t Know

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Where are we with admin simplification?C L A I M A T T A C H M E N T S

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The Health Insurance Portability and Accountability Act of 1996 (HIPAA; Pub.L. 104–191, 110 Stat. 1936)

So much progress….........So far to go

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Relationship of Standards and IGs WEDI/ASC X12/HL7 Attachments Collaboration Project (ACP)

Guidance on Implementation of Attachments for Healthcare Transactions

HL7 Documents

HL7 CDA Quick Reference GuideHL7 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 InformationASC X12N 275 Additional Information to Support a Health Care Claim or EncounterASC X12N 278 Health Care Services Review – Request for Review and ResponseASC X12N 275 Additional Information to Support a Health Care Services ReviewASC 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)

HL7 Supplementation Guide Publication

Date

NPRM/IFR ~ Q32 Month Comment Period Final Rule ~ Q4Implementation in 2 years ~Q4 2018

NCHVS Hearings - February 16 Letter of Recommendation? (2nd Qtr)

Conformance VersionMay Ballot – Reconciled by May 15 (earliest)

?Timeline for Attachments

XML (W3C Standard)

RIM

Consolidated CDA IG R1.1 (DSTU)

CDP1 IG

(DSTU)

Consolidated CDA R2 (DSTU)

Attachments Work Group Supplement

al Guide (Informative)

ASC X12N

277/275 TR3

 ASC X12N

278/275 TR3

 

Future IGs

CDA R2

LOINC

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How the industry is should be using electronic attachments?

o Healthcare Lines of Business- Auto and Workers’ Compensation (2008)- Dental - Commercial- Government

o Attachment Applications - Claim Adjudication and Post Adjudication- Referral/Notification- Prior Authorization

o Attachment Supported Formats - Clearinghouses- Unstructured Attachments (MSWord, PDF, Plain Text, RTF, HTML,GIF,TIF,JPEG, PNG)- Structured Attachments (C-CDA)

o Acknowledgments Consistent with the ARM- TA1 999 277CA 824

Post Claim AdjudicationValue-Based CareRisk AdjustmentQuality Reporting

Before ServicePrior AuthorizationPre-Certification

Claim AdjudicationClaims AttachmentDenials Appeals

These are traditional and future processes that involve claims attachments

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We know the problemsC L A I M A T T A C H M E N T S

Coming Soon

Contact

Download

Webinarswww.edifecs.com/insights

Webinar Recording Questions?info@edifecs.com

Blog

www.edifecs.com/e

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Document Types Review on “what” additional information (or types of attachments) are needed from providers?

10-20%All Claimsthat require medical

documentation

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Paper-Based Attachments

• Lost or misdirected requests.

• Lost or misdirected responses.

• The manual process for responding to additional

information request is cumbersome and slow.

• The manual process to re-associate the Attachments back

to the original claim submitted is cumbersome and slow.

• There is a lack of visibility (in the payer environment)

between the original documents, requests for information,

and the information returned from providers.

• There is a lack of acknowledgement mechanisms for the

provider to see if documents were received and associated

properly by the payer. Failures in the process can go

undetected for weeks or months.

• Manual processes and additional issues can add weeks or

months to the adjudication cycle, and can substantially

impact provider revenue.

Problems

Workflow Integration ChallengesNo Back-End Integration

Standards WarsNo clear direction from CAQH COREEmergence of DIRECT, FHIR

Impediments

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• EDI• USPS

ClaimUnsolicited

• EDI• USPS

Claim

• Claims System

Payer• Image Workflow

Payer

Solicited

Today’s Manual Process

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Perceived Challenges

Investment in scanning, document management systems and workflow by payers limits ROI. Provider ROI much higher.

Lack of consensus on a standard. No safe bet for investments.

Payers want and all provider solution, Providers want an all payer solution.

Lack of automation and integration into existing payer attachments processing (still no “automated decision making” for payer).

ClaimsAttachments

Why its taking so long to resolve?

Lack of workflow integration with provider billing and EMR systems.

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Still learning the true costsC L A I M A T T A C H M E N T S