Health plans are committed to reducing waste and inefficiency, but the healthcare industry as a whole still spends too much time and money manually managing administrative transactions. One report found that faxes account for almost 75 percent of all medical communication, and the 2017 CAQH report predicted administrative costs would reach $315 billion by the end of the year. These costs are driven largely by the continued reliance on phone calls, fax, and mail to manage claims transactions.
The good news is that the industry may finally be ready to tackle the problem. The U.S. Department of Health and Human Services (HHS) is expected to release its standards for automated attachments soon, but health plans shouldn’t wait until they are published to evaluate clearinghouse vendors who offer electronic medical attachment solutions. The following are some questions to ask.
Which workflows are supported?
Many attachment vendors support just a limited number of workflows—typically medical claims and workers compensation—but attachments (both solicited and non-solicited) are required across multiple health plan-provider transactions, including dental claims, prior authorizations, risk and quality measurements, appeals and overpayments, and more. Rather than deploy piecemeal solutions, health plans should look at enterprise-wide solutions that rely on an infrastructure that’s both flexible and scalable enough to meet the use case requirements across different departments.
How many submission modes are supported?
Health plans won’t see efficiency gains with automated attachments unless providers adopt the technology, so they should look for vendors that are flexible enough to meet providers where they are. This means offering multiple modes for submission such as a provider portal or direct submission from the EHR via HL7, x12, etc. Health plans should also consider the vendor’s ability to convert the data into a format that can be easily ingested into the plan’s systems. By partnering with vendors that offer a sophisticated platform, health plans may be able to minimize issues with back-end integration.
What are the requirements for file format and storage?
Vendors should be able to support structured formats (C-CDA) and non-structured formats (.doc, .xls, .jpeg, .tiff, .gif, .png, .zip, .pdf, etc.). File storage requirements will affect pricing, so health plans should know their internal document retention policy in advance of these conversations.
Do they support rules-based submissions?
Depending on the vendor’s capabilities, health plans may have the option of implementing rules designed to notify providers about an attachment being due. By creating automated requests based on 837 rules, health plans can prevent claims from entering the adjudication system without the required documentation. This minimizes the time a claim sits in pended status, reducing A/R time for providers and penalties related to prompt payment for health plans.
Electronic attachments have the potential to significantly reduce administrative costs, and aligning with the right vendor is a critical first step. Learn more about Availity’s clearinghouse and medical attachment solutions, or request a demo today.