4 EDI and Claims Investments Your Clearinghouse Should Be Making
Claims and clearinghouse services encompass everything from verifying patient eligibility to claims processing to handling all forms of payer payments. And given the changing reimbursement landscape, your EDI vendor should already be investing in more robust claims management technology and industry leadership activities.
Here are a few things to keep top of mind as you assess claims management vendors – investments your clearinghouse should be making (or have made already).
#1 Automating claims follow-up and monitoring
When healthcare organizations submit claims to their payers, it can feel a bit like the claims are lost in limbo – with no real insight into what’s happening overall or where individual claims are in the processing stage.
It can also be difficult to monitor delays or anomalies across thousands (and thousands) of claims. And even when you monitor manually – how do you decide whether the delay is meaningful or well within the payer’s typical reimbursement behavior for that type of claim?
After all, it takes time and money to follow up with payers – and the teams responsible for this work can easily find themselves chasing red herrings if they don’t know which delays to worry about. Your clearinghouse is the conduit between you and your payers – and they should be proactively adding value by leveraging their connections to payers’ systems and aggregated performance data. So look for your clearinghouse to be investing in automation and intelligent monitoring – giving you insight into payer performance and making sure you only invest time into follow-up when it’s truly necessary.
#2 Unifying claims management and value-based programs
Claims data underpins or is the primary basis for nearly all commercial and government payer value-based initiatives. This isn’t anything new—think PQRS—but it is expanding as value-based care accounts for a greater and greater percentage of healthcare overall.
Similarly, claims data isn’t a “new” priority for leading-edge healthcare organizations. (Healthcare Informatics’ 2014 coverage of Kaiser Permanente and Intermountain Healthcare combining claims and clinical data speaks to that.) But given CMS’ specific targets for value-based reimbursement, your clearinghouse should have a strong hand in value-based program reporting. They should already be investing in solutions that help you achieve exceptional value-based program performance.
#3 Easing the pains of reconciliation and eliminating lost remits
Healthcare reimbursement isn’t getting any simpler – in fact, it’s shifting rapidly from the more straightforward fee-for-service model to remarkably diverse and complex forms of value-based reimbursement. Consider: you might submit a claim for care that you were already paid for as part of a population or group payment ahead of time. You might receive a remit that bundles together all the various payments for the three or four (or more!) providers who were part of the care team.
Add to this the occasional paper check or EOB – they’re still out there – and it’s easy to see how managing remits & deposits in the coming years could become one of the real bottlenecks for any healthcare organization. Your claims management vendor should be investing in technology that ensures “any” doesn’t include you.
#4 Providing direct input to groups that advise CMS and create industry standards
Your clearinghouse should have a strong voice in the industry – because they’re your voice. You’ve probably heard some form of the saying, “As CMS goes, so go the commercial payers.” This isn’t just because CMS is so large a payer (though that doesn’t hurt). It’s because CMS leaders recognize that any changes they make aren’t sustainable if those changes aren’t adopted and scaled at the commercial-payer level.
CMS also recognizes that the vital voices in the equation include the clearinghouses, MACs, and other stakeholders that “make it all happen.” Whether it’s WEDI, The Cooperative Exchange, ASC X12, or individual workgroups organized by CMS, it’s key your clearinghouse be able to listen – and advocate – on your behalf.
This article was originally published on ZirMed and is republished here with permission.