Delivering Value Through Electronic Healthcare Attachments BY LeAnn - PowerPoint PPT Presentation

Delivering Value Through Electronic Healthcare Attachments BY LeAnn Morris, DentalXChange Moderator/Clearinghouse Nicole Smith, NEA, Vendor Ted Rendahl, CIGNA, Payer

Introduction – LeAnn Morris u LeAnn Morris, Vice President of Business Development, with DentalXChange since 2008 with over 30 years of industry experience. u DentalXChange has been working with payers and third party vendors in support of the 275 transaction for attachments. This, along with web based provider solutions designed to manage the customization of validation rules by specialty and by provider, helps to assure improved claim processing.

Introduction to Harley & Louie

As they say never leave cash on the table or in my world never leave the door open!

Introduction – Ted Rendahl, CIGNA u Ted Rendahl is currently a Business Project Specialist at CIGNA focusing on EDI and Digital Solutions. Ted has 11 years of experience in the healthcare industry, all with CIGNA, concentrating on EDI and Digital Solutions for the past 6 years.

CIGNA celebrates being LIVE with the 275 u Cigna went LIVE in 2016 u CIGNA was the first known national payer to support the 275 transaction u Payers? Who’s next? u Who is working on their 275?

Being First and was it a Challenge u CIGNA choices? u Portal, Partner vs. 275? u Availability, Quality, additional benefits? u How long did it take to go live? u 2 Years+ between, development, testing and production pilots u What where the hurdles along the way? u Formatting of BIN Segments and claim/attachment matching logic u File size limitations u Image quality, both of text as well as x-rays and perio-charting u Provider adoption u Kathy Weintraub shared “value of enhanced validations by plan level and specialty are something we have never supported”

It was NO Challenge, just benefits! u Lower cost for both payer and provider u Per 2017 CAQH Index Health Plan savings are $1.64 and Provider savings are $0.51 for electronic attachments u Faster turn around times for claim processing and payment u Ability to define scenarios/codes up front that always require an attachment, resulting in reduced claim pends u How is Cigna doing today? u In production with multiple Clearinghouses for the dental 275 unsolicited transaction u Currently piloting the medical 277RFAI and Solicited 275 transaction with plan to eventually rollout to Dental

Introduction to Nicole Smith, NEA u Vice President of Payer and Partner Services u Executive leadership team member responsible for architecting the strategic growth and management of NEA powered by Vyne's Payer and Partner Services. Responsible for leveraging NEA's businesses, products and services to address emerging market opportunities and the challenges posed by healthcare reform and the rapidly evolving technology landscape. Accomplished sales, marketing and management executive with over 15 years experience in the healthcare industry.

NEA solutions and Services Vyne By the Numbers 2019 Years in Business: More than 20 years u Number of Clients: u u Medical = over 900 500+ Trace hospitals / health systems u 400+ Fast Attach hospitals / health systems u u Dental = over 70,000 dental practice offices / over 110,000 dental providers Number of Plans & Payers: u u Medical = 50+ (Commercial & Medicare) u Dental = 750+ Number of Images & Attachments Transmitted: u u Medical = Over 4M images per month u Dental Over 3M images per month u Over 2M attachments per month u

Current State Industry lacks a 275 mandate – numerous delays, rule not finalized • Once mandated – two years to comply • Dental payers are not asking NEA for a 275 transaction • Entered agreement with Cigna for medical 277 RFAI / /275 pilot •

Unsolicited Workflow Payer accesses NEA PayerWeb • Claim Reviewed and approved or • Claim created • Attachment denied for created and additional submitted information Provider alerted of payer specific attachment requirements by procedure code. Provider Reimbursed

Solicited Workflow Provider submits Released for requested images • Claim denied or payment electronically pended for • Payer reviews additional claim and • Reimbursement • Final information • Requested associated received adjudication, images are images claim approved submitted with or without a new Payer accesses Payer rejected claim Remittance claim NEA PayerWeb to requests additional advice view images information via mail, phone call, 277 or NEA payer messaging

277/275 Workflow 277 RFAI 277 ACK • Provider • Provider prepares • Provider receives generates the attachment Acknowledgement • Payer receives the • Payer receives claim response claim, solicits 275, stores and additional information acknowledges file via structured transaction 275 transaction 837 file

Improving Attachment Services in coming years u Driving the ability to control provider validations down to the plan level. (i.e. - FEP programs that have different rules) u Provider Improvements? u Validations by provider/specialty u Validations by credentialing and or naughty list u Payer Improvements? u How do we get there as an industry?

Open to Questions from the NDEDIC attendees