Delivering Value Through Electronic Healthcare Attachments BY LeAnn - - PowerPoint PPT Presentation

Delivering Value Through Electronic Healthcare Attachments BY LeAnn Morris, DentalXChange Moderator/Clearinghouse Nicole Smith, NEA, Vendor Ted Rendahl, CIGNA, Payer

Introduction – LeAnn Morris

u LeAnn Morris, Vice President of Business Development,

with DentalXChange since 2008 with over 30 years of industry experience.

u DentalXChange has been working with payers and third

party vendors in support of the 275 transaction for

• attachments. This, along with web based provider

solutions designed to manage the customization of validation rules by specialty and by provider, helps to assure improved claim processing.

Introduction to Harley & Louie

As they say never leave cash on the table or in my world never leave the door open!

Introduction – Ted Rendahl, CIGNA

u Ted Rendahl is currently a Business Project

Specialist at CIGNA focusing on EDI and Digital

• Solutions. Ted has 11 years of experience in the

healthcare industry, all with CIGNA, concentrating

• n EDI and Digital Solutions for the past 6 years.

CIGNA celebrates being LIVE with the 275

u Cigna went LIVE in 2016 u CIGNA was the first known national payer to support the

275 transaction

u Payers? Who’s next? u Who is working on their 275?

Being First and was it a Challenge

u CIGNA choices? u Portal, Partner vs. 275? u Availability, Quality, additional benefits? u How long did it take to go live?

u 2 Years+ between, development, testing and production pilots

u What where the hurdles along the way?

u Formatting of BIN Segments and claim/attachment matching logic u File size limitations u Image quality, both of text as well as x-rays and perio-charting u Provider adoption

u Kathy Weintraub shared “value of enhanced validations by plan level and

specialty are something we have never supported”

It was NO Challenge, just benefits!

u Lower cost for both payer and provider

u Per 2017 CAQH Index Health Plan savings are $1.64 and Provider savings are $0.51

for electronic attachments

u Faster turn around times for claim processing and payment u Ability to define scenarios/codes up front that always require an attachment,

resulting in reduced claim pends

u How is Cigna doing today?

u In production with multiple Clearinghouses for the dental 275 unsolicited

transaction

u Currently piloting the medical 277RFAI and Solicited 275 transaction with plan to

eventually rollout to Dental

Introduction to Nicole Smith, NEA

u Vice President of Payer and Partner Services u Executive leadership team member responsible for

architecting the strategic growth and management of NEA powered by Vyne's Payer and Partner Services. Responsible for leveraging NEA's businesses, products and services to address emerging market opportunities and the challenges posed by healthcare reform and the rapidly evolving technology landscape. Accomplished sales, marketing and management executive with over 15 years experience in the healthcare industry.

NEA solutions and Services Vyne By the Numbers 2019

u

Years in Business: More than 20 years

u

Number of Clients:

u Medical = over 900

u

500+ Trace hospitals / health systems

u

400+ FastAttach hospitals / health systems

u Dental = over 70,000 dental practice offices / over 110,000 dental providers u

Number of Plans & Payers:

u Medical = 50+ (Commercial & Medicare) u Dental = 750+ u

Number of Images & Attachments Transmitted:

u Medical = Over 4M images per month u Dental

u

Over 3M images per month

u

Over 2M attachments per month

Current State

• Industry lacks a 275 mandate – numerous delays, rule not finalized
• Once mandated – two years to comply
• Dental payers are not asking NEA for a 275 transaction
• Entered agreement with Cigna for medical 277 RFAI / /275 pilot

• Claim created

Provider alerted of payer specific attachment requirements by procedure code.

• Attachment

created and submitted

Payer accesses NEA PayerWeb

• Claim Reviewed

and approved or denied for additional information

Provider Reimbursed

Unsolicited Workflow

Solicited Workflow

• Claim denied or

pended for additional information Payer rejected claim requests additional information via mail, phone call, 277 or NEA payer messaging

• Requested

images are submitted with

• r without a new

claim Provider submits requested images electronically

• Payer reviews

claim and associated images

Payer accesses NEA PayerWeb to view images

• Final

adjudication, claim approved

Released for payment

• Reimbursement

received

Remittance advice

277/275 Workflow

• Provider

generates the claim 837 file

• Payer receives the

claim, solicits additional information via structured transaction 277 RFAI

• Provider prepares

attachment response 275 transaction

• Payer receives

275, stores and acknowledges file 277 ACK

• Provider receives

Acknowledgement

Improving Attachment Services in coming years

u Driving the ability to control provider validations down to the plan

• level. (i.e. - FEP programs that have different rules)

u Provider Improvements?

u Validations by provider/specialty u Validations by credentialing and or naughty list

u Payer Improvements? u How do we get there as an industry?

Open to Questions from the NDEDIC attendees