healthcare payment & remittance · healthcare payment & remittance medical banking - best...

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


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


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


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.


Claim Payment Life Cycle

Provider

PayerAdjudication

Clearinghouse

PaymentERA/EFT Reconciliation

Claims Submission

Standard Electronic Healthcare Payment Cycle

Clearinghouse ACH

Healtcare service to patient

PaymentRemittance Advice

EFT/Check


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.


Provider Database

Print and mail

Electronic payment

Combining Administration and Financial Transactions

ERA

ERA

EFT

Reconciled

FirstProxy

USPS

Payer Healthcare Provider


Combining the Electronic Healthcare Payment’s Administrationand 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


Combining the Electronic Healthcare Payment’s Administrationand 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


Electronic Payments in Consumer Driven Health Plans and Funds

Fund Payment Life Cycle

Provider

Fund / Plan Administrator

Clearinghouse

PaymentAuthorization / funds transferFund / plan eligibility – fund withdrawal

Healthcare service to patient

Clearinghouse ACH

Eligibility / benefit verification

PaymentRemittance Advice

EFT/Check

ERA = Electronic Remittance Advice

ACH

Card swipe


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.


Electronic Payments in Consumer Driven Health Plans and FundsValue 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.


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.

Appendices

15

Traditional Electronic Payment Workflow

Payer claims receipt

Claimsadjudication

Accounts Payable

ERA preparation

Payer banking interfaceClearinghouse

batching, consolidation

and/or splitting logic

Payer Gateway data translator

(ANSI 835), ANSI edits connectivity







Clearinghouse batching,

consolidation and/or splitting

logic

ERA preparation

Provider’s 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


Healthcare Account Debit Flow

Eligibility / benefit plan

Enrollment / plan and fund

set-up


(eligibility/benefit verification –

ANSI 270/271) edits connectivity



Payer banking interface

Provider bank

Funds transfer

Financial debtBanking 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


(eligibility/benefit verification –

ANSI 270/271) edits connectivity

Provider office POS (card swipe) device

POS Technology

ERA = Electronic Remittance Advice


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


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

www.proxymed.com

healthcare payment & remittance · healthcare payment & remittance medical banking - best...

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