MEDE America Corporation is in the business of healthcare EDI. To that end, we “clean” and “clear” claim information and claim attachment information from the provider to the payer. Our definition of a claim is: An encounter or episode at a healthcare rendering facility that is recorded in a standard that is consistent with a specified electronic format. This information uses standard coding methods as defined by the third party payer across all lines of business. Our definition of an attachment is: Additional information required by a third party payer that is not defined in the standard claim submission across all lines of business in order for the third party payer to adjudicate the episode or encounter.
To differentiate information that is appropriate for the claim versus information that is appropriate for a claim attachment we must use the current electronic standards as a guide. Version IV, National Standard Format, X12N 837 and variations of these formats encompass what we know today as a “Claim”. Claim attachment information has taken on nearly all other data that cannot logistically be placed in the above stated formats or variations thereof.
MEDE America supports various electronic claim attachments. Our electronic format attachments are: physical therapy, speech therapy, occupational therapy, respiratory therapy, cardiac rehabilitation, medical social services, psychiatric therapy, skilled nursing, substance abuse, pacemaker, ambulance, and emergency room services. These attachments have non-standard electronic formats. They are electronic, but are typically not part of Version IV, National Standard Format, or X12N 837. We have found that an electronic attachment is usually manually keyed at the provider site into the third party payer’s specific format. This eliminates paper, but puts the manual labor on the shoulders of the provider. This method is preferred over the submission of paper by all involved.
MEDE America also supports scanned images that can be attached to a claim. We receive an electronic claim that is serialized to an electronic scanned image. From this point we print the claim and scanned images for mailing to the third party payer. This is a costly solution that still produces paper output, but is needed due to the increased requests for claim attachment information and an increase in third party payers that do not support electronic submission. The scanned images are usually Emergency Room reports or medical records. Commercial payers tend to require this information as well as Managed Care Organizations.
MEDE America supports detailed attachments. These attachments contain line item detail to the UB92 billing form. This detail is captured in a text format that is married to or serialized to a claim. From this point we print the claim and the detailed line item information for mailing to third party payers. This is a costly solution that still produces paper output, but is needed due to the increased requests for claim attachment information and an increase in third party payers that do not support electronic submission. Commercial payers tend to require this information as well as Managed Care Organizations.
Standardization is the only acceptable means if claim attachments will be required. We must have a finite list for claim attachments that have succinct, clear, and concise definitions. We must balance the need of the third party payers with the need of the providers. Forcing providers to a custom and proprietary format will force many of them to completely revamp their internal data transfer methodologies. Forcing third party payers to accept these same special formats will have the same drastic effect. We have worked with many agencies that set standards for data exchange. NUBC, NUCC or ANSI all have the capability to set the standard. The agency that is tasked to set the standard needs to have full representation from providers and payers to set a standard that is fair to both the provider and the payer. We need to examine what we are trying to standardize. We need to determine if the data is needed for immediate use, or if a yearly audit could be conducted to verify that compliance standards are met.
MEDE America realizes that change is difficult, but necessary, with claims and claim attachments. We need to mandate electronic claim submission not only at a federal level, but at the state level as well. We need to require, without exception, that workers compensation, no fault insurance companies, PPO’s, MSO’s, HMO’s, and IPA’s accept electronic claims in the X12N 837, Version IV, or the National Standard Format. We need to pick the standard for claim attachments and have a finite list that all parties involved can accept as necessary to adjudicate a claim. The impact from following these guidelines will be positive. We will reduce the cost of administration and allow for timely payment of claims. We can eliminate the manual intervention that causes the majority of payment errors or inappropriate denial of claims. We can stop the request for paper all together.
Recently MEDE America has been experiencing an increase in our central print center. We have been experiencing a growth in managed care organizations that will only take paper claims and paper attachments. These attachments are medical records, detail revenue code break down, emergency room reports, treatment plans, and various mandated forms. We seem to be moving away from electronic requirements back to paper. Whether we chose HL7, X12 with the 275 pilot, or look to ways to eliminate attachments all together; we must require electronic claim submission and electronic claim acceptance. Allowing paper claims and paper claim attachments will only increase healthcare costs to all of us.