HIPAA Summit EDI Enrollment A Manual Process in the EDI Chain Marcallee Jackson ProxyMed, Inc.

Today’s Objectives u Review the difference between Trading Partner Agreements and EDI Enrollment Forms u Review the common EDI enrollment processes for clearinghouses (CH’s) today u Discuss trends and their impact on the industry u Identify key requirements of the agreements u Discuss proposed alternatives to traditional processes

Two Agreements u Trading partner agreements – Most commonly entered into by two entities directly exchanging transactions – Defines the rules of engagement for each trading partner – May or may not require signature u EDI Enrollment – Serves as the provider’s request to exchange transactions with the payer – Contractually binds the provider and payer to certain requirements and conditions – Almost always requires a provider or officer’s signature

Common Requirements u Examining 1200 payers on a CH payer list – 27% require enrollment 73% of payers do not – Of the number that do, 78% are government plans and 22% commercial – Commercial payers requiring enrollment make up less than 6% of payers overall u Depending on a number of factors, the enrollment process takes weeks to complete u For claims, on average, a provider sending “all payer” to a CH will complete 4 separate enrollment forms along with the CH contracts and forms

Common Requirements u As much as 20% of CH FTE’s are dedicated to facilitating payer EDI enrollment u Forms are obtained from payers, distributed to providers and the CH most often supports the provider in completing the forms u CH’s normally track enrollment status and make calls to payers as necessary u When errors occur, the CH must identify and resolve them u Even when the process works well it is expensive and drains CH resources

Trends u Commercial payers are beginning to implement EDI enrollment u As health plans change intermediaries, business associates and systems, some are requiring re-enrollment u CH’s mergers and consolidations may require submitters to re-enroll under new submitter numbers u As submitters migrate from direct submission to the CH, or visa verse, a requirement for re-enrollment is likely u Often, new transactions, such as ERA, will require that existing submitters complete new forms

Impact u Increased administrative costs to everyone in the chain u Places an undo burden on the CH u Complicates the EDI process u Implementation timeline is extended u Providers perform selective implementation  Results in lower EDI volume

Key Requirements u Based on a cursory review of EDI enrollment agreements: – Assignment of CH as agent – Agreement to notify payer of a change in agent – Agreement to meet payer billing requirements – Agreement to exchange accurate and true data – Agreement to maintain source documents – Agreement to permit audit – Agreement to obtain any required consent

Key Requirements Continued... – Agreement to use unique identifiers – Agreement to meet testing requirements – Agreement to correct errors – Agreement to report problems/failed transmission – Agreement to protect privacy and confidentiality – Mandatory arbitration – Term – Contract termination

Key Requirements Continued... – Agreement to hold the payer harmless – Notice of the plan contractor’s obligation to provide no cost option – Provider listing with ID numbers

Alternatives u Universal language to be included in all service agreements between providers and CH's that address each requirement described here. u Provider assigns CH power of attorney for EDI enrollment. Example language: – Provider shall comply with procedures to secure any authorizations then required by, applicable law, or industry practice in connection with the. Provider hereby appoints as its attorney-in-fact for the limited purpose submitting Provider’s Transactions and/or signing paper Transactions on Provider’s behalf to third-party payers or processors, including, but not limited to, commercial insurers, Medicare, Medicaid and government agencies, and, where appropriate, agencies or carriers covering work-related accident or illness benefits, where Provider’s signature is required for processing or adjudication.

Alternatives Continued... u One form completed and signed, used for all payers u ANSI X Provider Enrollment transaction

Contributors Cooperative Exchange Association AFEHCT