Under the Affordable Care Act (ACA), a headlong push for digital financial transactions associated with healthcare was put in place among the more notable changes of that legislation. However, while the focus is generally on delivering easier transactions of healthcare provision and targeting how it is paid for, the actual implementation of that focus has been left to the healthcare industry to resolve.
As a result, payers and providers are looking to various approaches and levels of engagement in order to comply with the mandate. Some organizations have truly digitized every step of their transaction processing, while others are well embedded in paper processes. Here are three recommendations for why every healthcare provider should now be looking to engage in electronic management of payments and related processing:
Standardized Key Information in EFT and ERA Processing
Re-association trace numbers provide key tracking capability with any EFT or ERA originally generated by a given health plan. Implementation of these tracking tools is essential in both “paper trail” linkage on every transaction as well as preserving transaction history in general for the protection of the consumer, the plan, and the financial players involved.
Systems interacting with each other need to have a standard approach to how payments that move through them are either denied or modified. Transactions aren’t always perfect; there are valid reasons for corrections and returns. An agreed-upon code approach across the industry would be a welcome step in eliminating transactional confusion between different health plans and financial players.
1. The Continuing Development of ASC X12 Draft Policies and Similar Rules Already Passed
A provider should be able to choose between tracking on an NPI or tax ID number, and health plans should be able and willing to accommodate to either. Once accounts are established and in use, operating rules should require that all phases of a transaction have the ability to identify the health plan transacting in a given EFT payment or similar. When the transaction is finalized, there should always be an EFT receipt generated in a timely fashion (typically two business days between an EFT and ERA). Again, debiting and related reversals of EFT processing should follow standardized steps without variation between health plans (see ASC X12 835 v5010 standard requirements, NACHA standards, and operating rules for CCD+).
2. Potential Areas for Improving Current Standards
One of the key steps for electronic payment enhancement in the healthcare industry should be to make the standards more attractive for industry players to adopt. Again, the goal is to standardize across all players the same payment processing steps. However, if the suggested standards are considered too burdensome, companies and providers won’t participate. An approach that meets the financial needs of providers while also making it easy to maintain HIPAA compliance with privacy requirements would be most appealing and engaging. Furthermore, a standardized platform across a majority of providers and players would allow the possibilities of ERA data to move with EFT transactions versus the current necessity of having to apply re-association at the system receiving end.
A third challenge for providers is that many have already made significant investments in technology and are not inclined to suddenly change them out to a new system just to be compatible with others in the industry. The idea of scrapping what currently exists chafes most provider executive management at first mention. Rather than trying to force players to change their equipment and investments, attention should be focused on finding and promoting interoperability tools for EFT systems that are shared. Liaison or bridge tools allow all players to keep their investment assets and build on them instead. They would also allow already established ERA requirements to sufficiently remain in place without compliance loss.
One of the fastest ways to start generating a related discussion is for industry stakeholders to host and generate forums on ERA and EFT standards adoption, particularly in the area of interoperability tools. These discussions can increase awareness on the concept that financial institutions and health plans have common ground in payment processing system development. The lessons gathered from these discussions can then be used to help craft compliance standards that will support requirements, such as the ASC X12 v5010 835 Implementation Guide.