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Healthcare Payment & Remittance Medical Banking - Best Practices. Art Conklin, Director of FirstProxy and Electronic Payment Services. Electronic Healthcare Payment Session Objectives. Overview of medical banking models in the healthcare payment and remittance marketplace

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healthcare payment remittance medical banking best practices

Healthcare Payment & Remittance Medical Banking - Best Practices

Art Conklin, Director of FirstProxy and

Electronic Payment Services

electronic healthcare payment session objectives
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
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
the electronic healthcare payment managing the critical control points
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
healthcare electronic payment models
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.
standard electronic healthcare payment cycle

Clearinghouse

ACH

Standard Electronic Healthcare Payment Cycle

Provider

Healtcare service

to patient

Payment

ERA/EFT Reconciliation

Claims Submission

Claim Payment Life Cycle

Clearinghouse

Payment

Remittance Advice

EFT/Check

Payer

Adjudication

the standard electronic healthcare payment model
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.
combining administration and financial transactions

USPS

Healthcare Provider

Combining Administration and Financial Transactions

FirstProxy

Print

and mail

ERA

EFT

Provider Database

Reconciled

ERA

Electronic payment

Payer

combining the electronic healthcare payment s administration and financial transactions
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
combining the electronic healthcare payment s administration and financial transactions challenges
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
electronic payments in consumer driven health plans and funds

Card swipe

Electronic Payments in Consumer Driven Health Plans and Funds

Provider

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

electronic payments in consumer driven health plans and funds12
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 funds value add opportunities
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.
electronic healthcare payment summary
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.
traditional electronic payment workflow
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

healthcare account debit flow
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

Banking institution EFT transaction creation and routing

Financial debt

Provider bank

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

summary
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
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