Edifecs - Smarter.Clinical.Attachment
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Transcript of Edifecs - Smarter.Clinical.Attachment
1© E D I F E C S C O P Y R I G H T 2 0 1 6
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 [email protected]
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