Presentation on theme: "Healthcare Payment & Remittance Medical Banking - Best Practices Art Conklin, Director of FirstProxy and Electronic Payment Services."— Presentation transcript:
Healthcare Payment & Remittance Medical Banking - Best Practices Art Conklin, Director of FirstProxy and Electronic Payment Services
2 Confidential Information Electronic Healthcare Payment Session Objectives Overview of medical banking models in the healthcare payment and remittance marketplace Exploring best practices with an eye on: – ROI – Inter-operability – Auditing – Reconciliation Context – emerging marketplace
3 Confidential Information The Electronic Healthcare Payment Critical Success Factors Transaction flow controls Operational efficiencies, savings and profitable revenues. Reconcile billed to paid. Reconcile financial to administrative, the ERA to the EFT. Efficient Customer Support Connectivity is the key
4 Confidential Information The Electronic Healthcare Payment Managing the Critical Control Points Transaction standards Systematic reconciliation On-line ERA management tools Consistent operational practices, such as enrollment Linking ERA and EFT Meaningful adjudication codes Purging the paper and handling Fitting the pieces together
5 Confidential Information Healthcare Electronic Payment Models Standard healthcare claim and payment – Provider to Plan to Provider Combining the administrative (ERA) and financial payment transactions (EFT) – Outsourcing payment components Consumer driven plans and healthcare funds – Greater member responsibility for selecting services & allocating payment.
6 Confidential Information Claim Payment Life Cycle Provider Payer Adjudication Clearinghouse Payment ERA/EFT Reconciliation Claims Submission Standard Electronic Healthcare Payment Cycle Clearinghouse ACH Healtcare service to patient Payment Remittance Advice EFT/Check
7 Confidential Information The Standard Electronic Healthcare Payment Model Clearinghouses process 835 from Payer to Providers Payers bank processes EFT to Providers bank Support Vendor Intermediaries On-line management & support tools. Building partnerships to provide quality, value add products & services. Priced to produce savings and profitable revenues.
8 Confidential Information Provider Database Print and mail Electronic payment Combining Administration and Financial Transactions ERA EFT Reconciled FirstProxy USPS Payer Healthcare Provider
9 Confidential Information Combining the Electronic Healthcare Payments Administration and Financial Transactions EFT capability through ERA. ERA-EFT reconciliation. Single management tool for both payment transactions. Consistent operational workflow Efficiencies multiplied Fully outsourced payment functions FirstProxy
10 Confidential Information Combining the Electronic Healthcare Payments Administration and Financial Transactions - Challenges Realignment of traditional partnerships in managing healthcare payments. Slower than expected market acceptance to outsourcing payment function. Final completion of Phase 1 of HIPAA Transactions Recognition of value equation FirstProxy
11 Confidential Information Electronic Payments in Consumer Driven Health Plans and Funds Fund Payment Life Cycle Provider Fund / Plan Administrator Clearinghouse Payment Authorization / funds transfer Fund / plan eligibility – fund withdrawal Healthcare service to patient Clearinghouse ACH Eligibility / benefit verification Payment Remittance Advice EFT/Check ERA = Electronic Remittance Advice ACH Card swipe
12 Confidential Information Electronic Payments in Consumer Driven Health Plans and Funds Multi purpose benefit card is emerging to handle member payment responsibilities in consumer driven health plans and funds. – Credit / Debit of accounts – Administrative transactions, e.g. eligibility / benefit verification. Fits into provider workflow. Newer technology for POS devices permits for larger data requirements.
13 Confidential Information Electronic Payments in Consumer Driven Health Plans and Funds Value Add Opportunities Credit funds beyond debit accounts. Claim submission as component. Integrated eligibility and benefit verification to determine who is responsible for what of the treatment costs. Advance payment for plans payment responsibility.
14 Confidential Information Electronic Healthcare Payment Summary Electronic payment with value-added services (i.e. Web management tool). ERA/EFT combination via strategic partnership. Multi-purpose benefit card support. Value add products & services where opportunities exist. Priced according to value.
Traditional Electronic Payment Workflow Payer claims receipt Claims adjudication Accounts Payable ERA preparation Payer banking interface Clearinghouse batching, consolidation and/or splitting logic Payer Gateway data translator (ANSI 835), ANSI edits connectivity Payer Gateway data translator (ANSI 835), ANSI edits connectivity Payer Gateway data translator (ANSI 835), ANSI edits connectivity Payer Gateway data translator (ANSI 835), ANSI edits connectivity Clearinghouse batching, consolidation and/or splitting logic ERA preparation Providers proprietary software posting PMS posting software Banking institution EFT transaction creation and routing Provider bank Funds transfer Network Provider Accounts Receivable Provider claims submission Reconciliation Online EPP Manual posting ERA/EFT Process 16
17 Confidential Information Healthcare Account Debit Flow Eligibility / benefit plan Enrollment / plan and fund set-up Payer Gateway data translator (eligibility/benefit verification – ANSI 270/271) edits connectivity Payer Gateway data translator (ANSI 835), ANSI edits connectivity Payer banking interface Provider bank Funds transfer Financial debt Banking institution EFT transaction creation and routing Plan Sponsor Gateway – data translator (ANSI 834), ANSI edits connectivity Plan Sponsor Gateway – data translator (ANSI 834), ANSI edits connectivity Plan Sponsor Fund Funds transfer Payer Gateway data translator (eligibility/benefit verification – ANSI 270/271) edits connectivity Provider office POS (card swipe) device POS Technology ERA = Electronic Remittance Advice
18 Confidential Information Summary ProxyMed is the nations ONLY full suite of healthcare business solutions, offering beginning-to-end solutions. Transform the remittance advice and payment process from paper-based to electronic, resulting in: – Automated healthcare claims payment and settlement processes – Improved efficiency – Reduced costs Verify eligibility and benefit information prior to administering healthcare services, resulting in: – Improved administrative overhead – Better cash management – Expedited payment
19 Confidential Information ProxyMed Can Help You Achieve Success By… Enabling you to focus on core competencies Functioning as your single source for all administrative transactions Increasing productivity by reallocating resources Expediting payment process Maximizing profits through increased efficiencies Enabling you to focus on core competencies