Horizon Blue Cross Blue Shield of NJHIPAA Readiness Michaela Nardella Director, EDI Services 973-466-7276
HIPAA Readiness Case Study… What have we Done? • Received Certification through ClarEDI and Edifecs • Conducted 50+ Provider Seminars Statewide • Co-Authored the NJ Consensus Companion Guides • Designed a HIPAA Compliant Provider Portal • Enhanced Horizon’s Desktop Software – HorizonNet2000 to ensure HIPAA Compliance
HIPAA Readiness Case Study… What Have We Done? • Pilot with Source One Physician Group • Offering Electronic Funds Transfer to Physicians who receive certification through ClarEDI • Funding that ClarEDI certification • SourceOne Representative is working with the Vendor to identify the Electronic Submission Errors
HIPAA Readiness Case Study… All of That…and Still… • WebMD Conducted a Study on Electronic Claims: • Sampled 20M Professional claims; approx. 1 Million Horizon per month • Included 300,000+ Physicians; approx. 7,500 Horizon submitters • Virtually every Major Payer Represented
Native top errors Rendering Provider Name Indicator invalid Provider Signature indicator Facility Name Rendering Provider Name Rendering Provider Secondary Identifier invalid Moderate top errors Rendering Provider Name Indicator Other Insurance Type Code Other Payer Name Rendering Provider Secondary Identifier invalid Referring Provider Identifier invalid HIPAA Readiness Case Study…
HIPAA Readiness Case Study… Can we improve professional claims? • Even after WebMD applies processing edits and default values are allocated, providers need to assure that: • Referring provider secondary indicator is valid • Referring provider Identifier is valid • Facility postal code/zip code is valid • Procedure modifier is valid • Procedure code is valid • Rendering provider first name unexpected as entity is not a person.
HIPAA Readiness… What’s Next? • Horizon has authorized WebMD to default data temporarily to achieve an increased first pass rate and to assist in assuring cash flow • Continue to Evaluate WebMD Guidance reports on Professional Claims • In the process on analyzing WebMd Dental Guidance Reports • Await WebMD Institutional Guidance Reports • EDUCATE..EDUCATE..EDUCATE..EDUCATE
HIPAA Readiness … The Good, The Bad & The Ugly • The Good: • Horizon’s Contract with WebMD as our Exclusive Clearinghouse puts us in a good position to address a large volume of our claims • The Bad: • Providers/Submitters are STILL not ready for HIPAA, and must remain reliant upon clearinghouses • The UGLY: • Not all Payers have an exclusive clearinghouse, and will be required to do this analysis with each one