Electronic Claims Attachment Electronic Claims Attachment Pilot Pilot Presented by: Maria Ward Member, WEDI Advisory Task Group on Empire Pilot Co-Chair, HL7 Attachments Special Interest Group Co-Chair, WEDI Claims Attachments WG
Pilot Overview Pilot Overview Problem: Extremely manual paper-based process that increases provider Days Receivable Outstanding and contributes to high claims processing costs for payers Solution: Standards-based solution for exchanging data electronically
Pilot Overview Pilot Overview CMS Pilot � EMS and WEDI proposal for pilot � EMS funded as a Medicare fee for service contractor � Funding was limited to a proof of concept and not a working model � Pilot information available at the EMS website: www.empiremedicare.com
Purpose Purpose Demonstrate the use of standards in the exchange of electronic claim attachments between a payer and providers � Request X12 277 Version 4050 � Response X12 275 Version 4050 � Response HL7 CDA Release 1.0 � LOINC
EMS Selects Participants EMS Selects Participants EMS vendors to assist with Practice management vendor the payer end of the Pilot selected � Claredi � ViPS � NextGen Montefiore Hospital – Part A and � Several providers selected to Part B participate Memorial Sloan Kettering Cancer � Center –Part A � Horizon Eye Care – Part B � Hudson Eye Physicians – Part B � Urological Surgical – Part B
Objective Objective 277 Transaction 275/CDA Successfully used by � Provider able to generate using the medical record information provider in place of paper at their facility/office request � Payer able to translate and process Medical Claims Examiners Consistent claim adjudication decisions based upon the electronic attachment
Scope Scope � Medicare shared system modifications would not be made. � Solicited 275 only � Attachment types representing highest volume � Rehabilitation Services � Clinical Reports � All received X12 275/CDAs will be processed as HDV � Pre-pay medical review requests only
275 Payer Approach 275 Payer Approach � X12 275/CDA files received by EMS and transmitted to Claredi for processing � Claredi unbundling process used to separate the X12 275/CDA into component parts � Validation of the X12 275/CDA file based on the standards � Claredi produced several files for each valid X12 275/CDA file
Benefits Benefits � Providers will see benefits by: � Reduced processing time by control receipt of the 277 � Reduce review by clinicians result in lower processing costs. � Reduced untimely denials with the automated response.
Benefits Benefits � Payer return on investments � Eliminate paper request mailing – Reduce costs - $25,000 � Eliminate paper attachments handling – Reduce costs - $86,000 � Reduce appeals and adjustments from untimely denials – Potential savings - $143,000
Pilot Findings Pilot Findings � Demonstrated that the standards were successful in the exchange of both the request and the response. � Need to supplement X12 expertise with HL7, XML, MIME technical and clinical expertise. � Discovered minor discrepancies in the standards documentation. � Six Claims Attachments standards met 86% of the Medicare medical review business needs. � Claim payment determination consistent with paper attachments.
Pilot Findings Pilot Findings � Data included on the electronic attachment was equal to the paper attachment, no more no less. � Full medical records were not exchanged. � Institutional providers attachments ranged from 1 to 68 pages and from 2.2 MB to 190 MB in size. � Professional providers attachments ranged from 1 to 4 pages and from .01 MB to 1.3 MB in size. � BIN segments were not greater than 8 MB. � 277 request alone is valuable
Pilot Findings Pilot Findings � Paper requests not always specific � Medical policies not met 100% with proposed six attachment types – Will vary across payers � Allows for the exchange of scanned/imaged documents
Next Steps for EMS Next Steps for EMS � Move X12 277 request to production for EMS Medicare providers. � Assess the X12 275/CDA for production
Next Steps for the Industry Next Steps for the Industry � Enhance your HIPAA X12 transaction knowledge to include claim attachments � Analyze current requests to determine business requirements � Analyze document storage systems � Analyze your ability to integrate financial and clinical systems.
Thank You Thank You � EMS Pilot information is available on the Empire Medicare Services web site: http://www.empiremedicare.com/hug/ECAPfiles/ecapindex.htm � Questions contact: Mary Lynn Bushman Mary.Bushman@Empireblue.com (717) 565-3697
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