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Healthcare Payment & Remittance Medical Banking - Best Practices
Art Conklin, Director of FirstProxy and Electronic Payment Services
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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
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The Electronic Healthcare Payment Critical Success Factors
Connectivity is the key 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
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The Electronic Healthcare Payment Managing the Critical Control Points
Fitting the pieces together 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
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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.
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Standard Electronic Healthcare Payment Cycle
Provider Healtcare service to patient Payment ERA/EFT Reconciliation Claims Submission Claim Payment Life Cycle Clearinghouse Clearinghouse ACH Payment Remittance Advice EFT/Check Payer Adjudication
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The Standard Electronic Healthcare Payment Model
Clearinghouses process 835 from Payer to Provider’s Payer’s bank processes EFT to Provider’s 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.
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Combining Administration and Financial Transactions
FirstProxy USPS Healthcare Provider Print and mail ERA EFT Provider Database Reconciled Proprietary, Internet-based registration process that relieves a payer from attempting to secure their providers’ banking information Advanced notice of direct deposit and electronic remittance advices via automated notification Embedded web link accesses the payment’s corresponding remittance advice ERA Electronic payment Payer
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EFT capability through ERA. ERA-EFT reconciliation.
Combining the Electronic Healthcare Payment’s Administration and Financial Transactions FirstProxy EFT capability through ERA. ERA-EFT reconciliation. Single management tool for both payment transactions. Consistent operational workflow Efficiencies multiplied Fully outsourced payment functions
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Final completion of Phase 1 of HIPAA Transactions
Combining the Electronic Healthcare Payment’s Administration and Financial Transactions - Challenges FirstProxy 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
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Electronic Payments in Consumer Driven Health Plans and Funds
Provider Card swipe Healthcare service to patient Payment Authorization / funds transfer Fund / plan eligibility – fund withdrawal Eligibility / benefit verification Fund Payment Life Cycle Clearinghouse ACH Clearinghouse ACH Payment Remittance Advice EFT/Check Fund / Plan Administrator ERA = Electronic Remittance Advice
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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.
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Credit funds beyond debit accounts. Claim submission as component.
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 plan’s payment responsibility.
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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.
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Appendices 15
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Traditional Electronic Payment Workflow
ERA/EFT Process Payer Gateway data translator (ANSI 835), ANSI edits connectivity Payer Gateway data translator (ANSI 835), ANSI edits connectivity Payer claims receipt Claims adjudication Accounts Payable ERA preparation Payer banking interface Clearinghouse batching, consolidation and/or splitting logic Funds transfer Payer Gateway data translator (ANSI 835), ANSI edits connectivity Reconciliation Provider bank Banking institution EFT transaction creation and routing Online EPP Network Manual posting Clearinghouse batching, consolidation and/or splitting logic Payer Gateway data translator (ANSI 835), ANSI edits connectivity PMS posting software ERA preparation Provider’s proprietary software posting Provider claims submission Provider Accounts Receivable 16
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Healthcare Account Debit Flow
POS Technology Payer Gateway data translator (eligibility/benefit verification – ANSI 270/271) edits connectivity Payer Gateway data translator (ANSI 835), ANSI edits connectivity Eligibility / benefit plan Enrollment / plan and fund set-up Payer banking interface Plan Sponsor Gateway – data translator (ANSI 834), ANSI edits connectivity Funds transfer Payer Gateway data translator (eligibility/benefit verification – ANSI 270/271) edits connectivity Financial debt Provider bank Banking institution EFT transaction creation and routing Proprietary, Internet-based registration process that relieves a payer from attempting to secure their providers’ banking information Advanced notice of direct deposit and electronic remittance advices via automated notification Embedded web link accesses the payment’s corresponding remittance advice Funds transfer Plan Sponsor Gateway – data translator (ANSI 834), ANSI edits connectivity Plan Sponsor Fund Provider office POS (card swipe) device ERA = Electronic Remittance Advice
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Summary ProxyMed is the nation’s 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
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ProxyMed Can Help You Achieve Success By…
Enabling you to focus on core competencies Maximizing profits through increased efficiencies Expediting payment process Increasing productivity by reallocating resources Functioning as your single source for all administrative transactions Enabling you to focus on core competencies
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