It’s been a busy and rewarding month! We connected with our CHIE customers, sharing valuable insights and updates on the new portal experience. We proudly took part in recognizing the Utah Model of Care as a member of the One Utah Health Collaborative’s Stakeholder Community Board. On top of that, we posted the top five takeaways from our virtual payer panel, attended the Texas Association of Health Plans conference, and shared that Brian Chin will assume the role of Chief Product Officer at Comagine Health, in addition to his position as CEO of UHIN.
The new CHIE portal is live, offering a more modern user interface to access your patients’ longitudinal health records. We’ve created several methods to set you up for success.
CHIE portal users can watch engaging videos that walk you through the new portal features and powerful new tools, and how to log-in through MYUHIN.
Additionally, users can dive deeper into our comprehensive user guide which breaks down every feature step-by-step.
Prioritizing a System that is “Affordable, High-Quality and Built on Trust”
The One Utah Health Collaborative announced the adoption of the Utah Model of Care at the Capitol in late October. The model, developed through statewide collaboration, represents a significant step toward creating a healthcare system that is affordable, high-quality, and trusted for all Utahns. UHIN is proud to be part of the Stakeholder Community Board working with the One Utah Health Collaborative on the Utah Model of Care!
Top Questions and Answers from the Virtual Payer Panel
Dive into five of the top questions and insights shared during the webinar with Lori Weber (Noridian Healthcare Solutions) and Melissa Shoemaker (Select Health), offering clarity on telehealth billing, claims processing, EDI recertification preparation and other essential topics.
We attended the Texas Covered Health Care Conference + Expo Event in Austin, TX from November 4-6.
UHIN will be closed for the Thanksgiving holiday on Thursday, November 28th and Friday, November 29th. We’re thankful for our customers, colleagues, community and partners!
Please note: UHIN Customer Support Holiday Schedule
The UHIN Customer Support call center will be closed on Thursday, November 28th and Friday, November 29th. All regular support issues will be addressed on Monday, December 2nd.
Our on-call team will actively monitor the system to ensure connectivity remains stable. If you have an issue, please contact us through the standard support channels by emailing customersupport@uhin.org. These will be addressed in accordance with our off-hours support policies.
Trainings and Webinars
Watch the CHIE Portal Overview Video
The new platform offers a more modern user interface to access your patients’ longitudinal health records. Learn more about the updated experience in our demo video, including the new dashboard, cards, patient summary, customer support, and future enhancements.
Brian Chin tapped as Comagine Health’s Chief Product Officer
Comagine Health recently announced that Brian Chin will take on the role of their Chief Product Officer, while continuing to serve as CEO of UHIN. In his expanded role, Mr. Chin will lead the development and execution of Comagine Health’s product and technology roadmap, driving their commitment to providing high-quality solutions that meet the changing needs of the clients and the communities they support.
Happy Halloween! This month, we moved to the new CHIE portal, hosted portal webinars and Q&As (one more coming up!), hosted a virtual payer panel with panelists from Select Health and Noridian Healthcare Solutions, LLC, attended the CIVITAS Annual Conference, and posted about the ideal clearinghouse solution for large healthcare providers on our blog.
We moved to our new CHIE portal experience on Wednesday, October 30. The new portal offers a more modern user experience, including a new Patient Summary page and cards for allergies, encounters, immunizations, and more. Users will also be able to download a CCD and look back to specific periods of time, among other features.
Interested in learning more about the new CHIE portal experience? We’ve created several methods to set you up for success. You can explore its features and functionality in the following ways:
1. Watch the portal video on YouTube 🎥 Check out our engaging video that walks you through the portal’s layout and highlights some of the powerful new tools available. Perfect for when you need a high-level overview!
2. Review the portal user guide 📖 For those who prefer to dive deeper, our comprehensive user guide breaks down every feature step-by-step. Think of it as your go-to resource for answers to your questions.
3. Attend Our Webinars 📅 We’re hosting a live webinar next week, where we’ll answer your questions in real time. Join us on Monday for an interactive session – and come with questions!
CHIE Webinar: New Portal Questions and Answers Monday, November 4, 2024 | 12 p.m. MT Click to register
From the UHIN Blog
The Ideal Clearinghouse Solution for Large Providers
A robust claim management solution covers all of your needs: consolidates all payer connections into a single, reliable network, reduces administrative costs and labor, improves cash flow, delivers real-time eligibility, and supports EDI enrollment. Read this month’s blog post about the benefits the UHIN Clearinghouse delivers for large healthcare providers.
We attended the Civitas Annual Conference in Detroit, MI from October 15-17.
November 4-6: Texas Covered Health Care Conference + Expo Event in Austin, TX.
We will be closed Thursday, November 28 and Friday, November 29 for Thanksgiving.
Trainings and Webinars
Virtual Payer Panel
On Tuesday, October 29, we hosted a virtual payer panel with Melissa Shoemaker (Sr Network Engagement Representative Provider Development, Select Health) and Lori Weber (Education Representative II-Part B Provider Education, Noridian Healthcare Solutions, LLC). Our panelists answered questions and shared updates ranging from enrollment to coding, and from prior authorization to EDI recertification.
Watch the recording on our YouTube channel and look out for future payer panels coming soon!
Comagine Health, our affiliate partner, recently shared a link to this informative guide (by Katelyn Jetelina) on vaccines for all three fall respiratory viruses: flu, RSV, and Covid-19. Take a look and be in the know!
Keep scrolling for our final update on the Change Health Care cybersecurity event, the ways caregivers use the CHIE to manage falls amongst our older population, and how the Clearinghouse simplifies claim management for Providers. Plus, upcoming events, trainings, and conferences…
Final Update on UHIN’s Response to the Change Health Care Cybersecurity Event
We are pleased to announce that our efforts to restore full functionality following the cybersecurity event at Change Health Care (CHC) have been successful. Learn more about our streamlined enrollment processes, increased Electronic Remittance Advice (ERA) submissions, and updated payer list.
The week of September 23rd was Falls Risk Awareness Week. We took this time to bring attention to falls amongst our older population. Utilizing the CHIE’s Falls Risk Indicator, providers receive timely information about potential falls within their patient population, empowering them to contact patients with the right support to keep them healthy and independent.
September 26-27: Wisconsin Association of Health Plans Annual Conference in Elkhart Lake, WI October 15-17: Civitas Annual Conference in Detroit, MI
November 4-6: Texas Covered Health Care Conference + Expo Event in Austin, TX
Trainings and Webinars
Stay Tuned for What’s Coming Up!
In the months ahead, we’ll host Virtual Payer Panels and CHIE platform trainings. Sign up in the email preference center to stay informed of dates and details.
Interested in learning how to use the CHIE or MYUHIN to their fullest capabilities? Make sure to visit the UHIN Education channel to watch our how-to videos on YouTube.
Wrapping Up
National EDI Network for Providers
Learn how UHIN’s Clearinghouse, the nation’s only nonprofit clearinghouse, provides a modern, mission-driven claim management solution for Providers.
Leaders in healthcare electronic data interchange (EDI) must pursue peak performance in claim management and data excellence, akin to athletes pushing to win at the highest levels. Just as divers, gymnasts, cyclists, hurdlers, basketball teams, and sprinters train relentlessly to execute with precision, EDI leaders must remain focused, while taking meaningful actions to improve their operations every day.
The Pursuit of Perfect Precision
Divers focus on every detail to dive with precision from platforms up to 33 feet above the water and break the water with a splash-less entrance. For divers, hitting the surface with flat palms for a “rip entry” leads to a medal-worthy, tiny splash. Achieving excellence in claim management stems from meticulous attention to claim accuracy and closing the proximity of error. This pursuit involves reducing manual claim processes, refining validations, and improving auto-adjudication rates that will reduce costs and alleviate staff bandwidth. This makes the difference between winning gold and watching from the bleachers.
Automation of claims transactions could reduce the cost per transaction by up to 50% for health plans.
In the high stakes world of gymnastics, adaptation and innovation are key to staying ahead of the competition. Similarly, the healthcare industry is constantly evolving, and staying competitive requires embracing innovation and adaptation. From adopting cloud-based EDI solutions to integrating Fast Healthcare Interoperability Resources (FHIR), EDI managers must be at the forefront of technological advancements. These innovations are revolutionizing claim management in ways that will enable enhanced data accuracy and improve compliance with ever-changing regulations.
Harnessing the Power of Data
Data is the lifeblood of both cyclists and claim managers. For world-class cyclists, data-driven insights and performance metrics are crucial for fine-tuning their training regimens. Power output, revolutions per minute, heart rate, watt-to-weight ratio, and other data help cyclists cross the finish line first. In the realm of healthcare, harnessing the power of data can transform claim management. Health plans can leverage claim data in many valuable ways, like identifying high-utilizers who drive up costs and loss ratios, detecting fraud, optimizing payouts, and more. This proactive approach – rooted in data analysis – can lead to reduced costs, precise payouts, improved security, and enhanced efficiency across the business.
Overcoming Hurdles
To win gold, world-class hurdlers prepare rigorously to clear physical hurdles without losing momentum. Similarly, EDI managers face daily challenges like dealing with paper claims, EDI enrollment, and meeting claim resolution within the mandated time frame. The right claim management solution will help to alleviate daily issues, deliver accurate data and facilitate consistent communications that ensure a smoother path to claiming gold in data excellence.
The Role of Teamwork
Behind every successful team is a dedicated group of coaches, trainers, and support staff. In healthcare data management, teamwork is equally vital. Collaboration between EDI managers, IT and operations teams, and technology partners is essential for achieving peak performance. By fostering a culture of open communication and cross-functional cooperation, organizations can ensure that every team member is aligned with the common goal of excellence in data management. This collaborative effort results in seamless workflows, fewer errors throughout the claim lifecycle, and enhanced automation.
Celebrating Achievements
Every milestone reached on the track, whether it’s a personal best or a new world record, is a cause for celebration. In healthcare data management, it’s important to recognize and celebrate achievements. From achieving a new high in auto-adjudication rates to successfully implementing a new EDI system or resolving complex claim issues, these accomplishments are a testament to the hard work and dedication of the entire team. Celebrating these successes not only boosts morale but also reinforces the commitment to continuous improvement and excellence.
Health plans can deliver short-term business cost savings affecting about 10% of total payer expenses by aggressively simplifying operations in 2024.
Gartner | 2024
The Path Forward
In conclusion, claim managers at health plans can achieve excellence by adopting specific action items, such as refining validation processes, increasing their auto-adjudication rate, and ensuring secure transactions. Drawing inspiration from world-class athletes, they must remain focused, resilient, and committed to continuous improvement.
Leveraging data effectively and fostering teamwork are crucial for precise claim management and improving overall efficiency. Embracing innovation and adaptation will keep health plans competitive, cost-efficient and compliant in the evolving healthcare landscape. Thoughtful preparation and execution will help EDI managers overcome the hurdles on a daily and long-term basis. Coming together as a team, including with your EDI partner, leads to better communications, reduced manual work, and seamless workflows. Celebrating achievements, no matter how small, reinforces the commitment to excellence and motivates the entire team to strive for peak performance.
The journey may be challenging, but the rewards of excellence in healthcare data management are well worth the championship effort.
Partnering with an established leader in claim management, like UHIN, sets your health plan on a path towards EDI excellence. As a mission driven clearinghouse, UHIN approaches claim management differently: we pass cost savings on to customers, provide expert, US-based customer service, and focus on the success of our customers – not our own.
The Council for Affordable Quality Healthcare (CAQH) released their annual index report earlier this month. Data from the 2023 CAQH index sheds light on electronic administrative transaction adoption rates, areas of waste and cost avoidance, and the impacts of medical staffing shortages. At UHIN, we’ve recognized similar, significant trends through our claims management, specifically in claims submission, claims status inquiry and electronic remittance advice (ERA).
Here are our points of view and takeaways from the 2023 report:
Staffing shortages are a major issue
Electronic adoption increased
Cost and Time spent increased
Collaboration & flexibility are critical
Transaction findings:
Claims submission
Claims status
Eligibility and Benefits
ERA
1. Staffing shortages are a major issue
The COVID-19 pandemic strained the healthcare system, which led to significant staffing shortages that continue to impact the industry, especially for providers. The impact of the pandemic is felt most intensely in the time to conduct administrative tasks:
Provider time to conduct transactions increased in 2023, on average, 14 percent which accounted for 77 percent of the increase in total medical spend.
For the second consecutive year, time to complete electronic transactions grew. While staffing issues and transaction volumes increased, providers required more time to commit administrative tasks.
Staffing issues were felt in the hiring process as less experienced staff were onboarded who ”required more time to understand processes and requirements.”
Our MYUHIN billing and claim management solution helps ease the onboarding burden. An intuitive platform like MYUHIN won’t require hours of training to get the job done. New staff can get started quicker and manage your revenue and cash flow better from the start. Tools like Templates and Drafts reduce the time to submit claims. Everything will just fall into place for you.
2. Adoption increased:
In the “new normal” – as CAQH defines this era – adoption of electronic administrative workflows continued to rise in 2023 on the heels of new processes put in place during the pandemic. Per CAQH: “Automated tasks provided flexibility to staff as work environments changed and adapted to a new normal.” These transactions saw the greatest electronic adoption rate:
Remittance advice increased from 83% to 88%
Eligibility and benefit verification increased from 90% to 94%
Electronic claim status inquiries increased from 72% to 74%
Claim submission increased from 97% to 98% (almost reaching full adoption)
We noticed a rise in electronic claims submission this year, as well. MYUHIN delivered its one millionth claim in tandem with the uptick in submission volume. We empower you to accelerate your claim submissions, check coverage and benefits of patients in real time, and facilitate status inquiries from payers. These are all critical components to your revenue and cash flow management.
3. Cost and Time spent increased:
Per CAQH: “Despite the increase in electronic transactions and decrease in manual ones, overall spending on administrative tasks grew due to persistent staffing challenges impacting the time to conduct tasks.”
Provider time to conduct transactions increased 14% (on average), the second year that the time to complete electronic transactions has grown.
The amount of time for a provider to submit a claim can take up to 20 minutes for a paper claim and up to 10 minutes for an electronic claim.
Spending on claim submissions rose 67 percent to $19 billion
Medical providers reported spending, on average, 24 minutes on manual claim status inquiry, costing approximately $12 per transaction – the highest time and cost among the transactions along with prior authorization.
For providers, you can save time by checking eligibility and submitting claims with MYUHIN. If you want to reduce costs (who doesn’t??), our value pricing makes your decision to switch billing solutions a snap.
“With the data and technologies available to us today, we have the power to transform the way we conduct the business of healthcare. However, as an industry, we must align around consistent processes that enable providers to minimize the time spent learning new workflows. This is particularly important given the current labor shortage.”
Erin Weber, Chief Policy and Research Officer at CAQH (via CAQH)
4. Collaboration and flexibility:
Looking ahead, the CAQH index report notes: “As staffing concerns are expected to continue, the industry needs to work together to identify solutions and best practices for time savings.” Claim submission data was particularly dysfunctional between providers and payers, driving an increase in claim denials in 2023. We all need to work together to address the challenges in the medical industry.
We believe in interoperability for all. Healthcare is complex and challenging. Healthcare silos are ingrained in the industry. Where fragmentation begins, quality of care decreases and costs rise. When UHIN looks at the fragmented nature of healthcare we know we need to act and be a force for change.
5. Let’s dig into the transaction analysis:
Claim submission:
$2.1 Billion in cost savings opportunity annually for electronic claim submission
5 minutes in time savings opportunity per transaction for electronic claim submission for providers
Claims status inquiry:
The number of claim status inquiries conducted increased by 19%
17 minutes in estimated time savings opportunity per transaction
Medical providers reported spending, on average, 24 minutes conducting a manual claim status inquiry, costing approximately $12 per transaction – the highest time and cost among the transactions along with prior authorization
$3.2 Billion in cost savings opportunity annually for the medical industry
Eligibility and benefits:
Adoption of the electronic eligibility and benefit verification transaction increased 4 percentage points for the medical industry, one of the largest increases
Eligibility and benefit verification represents the highest volume transaction for the medical industry, accounting for 54% of all medical administrative transactions
16 minutes in time savings opportunity annually for electronic eligibility and benefit verification for the medical industry
$9.3 Billion in cost savings opportunity annually
Electronic remittance advice:
Adoption increased to 88% (the highest increase among the transactions)
$701M in cost savings opportunity annually for electronic remittance advice for the medical industry
5 minutes in time savings opportunity annually for electronic remittance advice for the medical industry
The Council for Affordable Quality Healthcare (CAQH) released their annual index earlier this month. Data from the 2023 CAQH index report sheds light on electronic administrative transaction adoption rates, time savings, cost avoidance, and the need for collaboration. The effects of the COVID-19 pandemic continue to be felt across sectors, adding to the strain of increasing costs, decreasing cost savings opportunities and increasing time spent on administrative tasks. Yet, there’s still hope. At UHIN, we’ve recognized similarly significant trends in our Clearinghouse transactions and claims management, specifically in claims submission and electronic remittance advice (ERA), and offer solutions that can move health plans to a more positive outcome for themselves and their members.
Our most intriguing takeaways from the 2023 CAQH index report:
Volume increased
Cost avoidance opportunities persist
Collaboration & flexibility will be key moving forward
Certain transactions make a big impact:
Claims submission (ASC X12N 837: request to obtain payment or transmission of encounter information for the purpose of reporting delivery of healthcare services)
Remittance Advice (ASC X12N 835: an explanation from a health plan to a provider about a claim payment)
1. Volume increased
The index report highlights that electronic transaction volume increased, but for one notable exception, in 2023 (for both payers and providers).
Electronic claim submissions increased from 8,751 to 9,476
Claim status inquiry increased from 2,254 to 2,820
Only Electronic remittance advice decreased, moving from 2,499 last year to 2,080 in 2023, marking a 22% decrease
We facilitate each of these transactions and provide other valuable services, like EDI enrollment, to health plans. Since 1993, we’ve empowered our customers to provide better care and better costs to their members. To this day, we remain at the vanguard of electronic data interchange (EDI) and interoperability. Are you ready to learn more about our claims management solutions?
Overall, the estimated medical industry spend increased from $55 Billion to more than $82 Billion, driven primarily by staffing shortages coupled with volume increases. In tandem, cost savings opportunities decreased to $16.4 Billion. The report reveals that $89 billion, or 22% of National Healthcare Expenditures in the U.S., is spent on administrative transactions, with potential savings of $18.3 billion through fully electronic transactions. Health plans can still save more than $140 million annually by automating transactions:
Savings opportunities:
$104 million with electronic claims submissions
$38 million by moving to electronic remittance advice
It’s important to remember that you don’t need to sacrifice quality when decreasing costs. UHIN provides high quality electronic claims management services at a comparatively low cost. We’ve been doing this for health plans for more than three decades and remain dedicated to our mission: Better costs and better care.
3. Collaboration and flexibility are key:
Looking ahead, the CAQH index report notes that the “industry will need to collaborate and remain flexible in order to identify opportunities and best practices, and respond to emerging and consistent challenges and business needs.”
We couldn’t agree more. Healthcare is complex and challenging. When UHIN looks at the fragmented nature of healthcare we know we need to act and be a force for change. As a central, neutral, community-created organization, we bring together all players in the healthcare environment to create a more connected healthcare system.
“With the data and technologies available to us today, we have the power to transform the way we conduct the business of healthcare. However, as an industry, we must align around consistent processes that enable providers to minimize the time spent learning new workflows. This is particularly important given the current labor shortage.”
Erin Weber, Chief Policy and Research Officer at CAQH (via CAQH)
4. Let’s dig into the transaction analysis:
Claims submission:
$2.1 Billion in cost savings opportunity annually for electronic claims submission for providers and payers combined
While electronic spend on claims by plans decreased in 2023 (from $576 Million to $517 Million), the total of costs avoided increased (from $4.2 Billion to $5 Billion)
Electronic remittance advice:
Adoption increased five percentage points across the medical industry to 88% (the highest increase among the transactions)
Medical volume decreased 22 percent
$701 Million in cost savings opportunity annually for electronic remittance advice across the medical industry
We’re excited to start sending our new newsletter in 2024. Each month we’ll share insights and articles from our in-house experts, HIT news, event announcements, product updates, and more.
Spotlight
What we did in 2023
We celebrated our 30th anniversary! Thank you to our founders, partners, board of directors, customers, and staff who have supported us for more than three decades.
We enjoyed seeing familiar faces and meeting new friends at the WEDI National Conference, Civitas Annual Conference, Texas and California Association of Health Plans Annual Conferences, AWS re:Invent, Utah Health Association Fall Leadership Conference, and the Utah Medical Association Annual House of Delegates Meeting.
We hosted the 2023 HIT Conference focused on the “Future of Healthcare Interoperability.” 250 attendees joined us in Salt Lake City to hear keynote addresses by Dr. Angela Dunn (Executive Director, Salt Lake County Health Department) and Joy Rios (Founder and CEO of the “HIT Like a Girl” podcast), and attended sessions with thought leaders from UHIN, the University of Utah Health, Select Health, Amazon, One Utah Health Collaborative, KLAS, Canary Speech, Comagine Health, healthKERI, HL7 International, Redstone, Brigham Young University, Shoreline, and Noridian Healthcare Solutions.
HIT News
1,000,000 MYUHIN claims
MYUHIN crossed one million claims submissions in 2023. Our billing solution empowers thousands of healthcare providers and billers to check eligibility and submit claims from anywhere. Click below to learn about all of MYUHIN’s benefits and predictable pricing.
UHIN’s Falls Risk Indicator ingests non-transport information from Emergency Medical Services (EMS) through the state’s National Emergency Medical Services Information System (NEMSIS) and uses an algorithm with data points from the patient record to provide a yes/no risk assessment of a patient’s risk of falling in the short term. As a physician using the CHIE, you can use the Falls Risk Indicator to be notified when your patients are at-risk for damaging falls, and then intervene. Read our recent blog post by Michelle Suitor (Director, Clinical Health Information Exchange) about the Falls Risk Indicator below!
We’ll be attending ViVe 2024 (Los Angeles, Feb. 25-28), WEDI Spring Conference (Virtual, May 13-16), and Civitas 2024 Annual Conference (Detroit, Oct. 15-17). We’ll continue to add more throughout the year!
Which conferences and events are you planning to attend this year? If you need some ideas, see Fierce Healthcare’s “Healthcare conferences to put on your calendar for 2024” below.
We’re preparing a series of online trainings this year for our customers. You will learn about new product features and have the opportunity to share feedback with our HIT experts. Stay tuned for more information about our upcoming trainings!
Wrapping Up
Add your story to our newsletter!
We’d like for our newsletter to include everyone: our customers, partners, industry experts, and anyone with a compelling story to share. Got something your peers in healthcare and tech just have to know? An innovative interoperability solution or point of view?
Please email us at communications@uhin.org and we’ll include links to our favorite community content each month.
Join our monthly newsletter and don’t miss anything!
More than one in four elderly people (ages 65 and older) suffer from a fall every year. Center for Disease Control and Prevention (CDC) statistics demonstrate that just one fall is a preamble to a far scarier story:
Falling just one time can double the chances of that elderly person falling again, which could lead to death
20% of falls result in serious injury
Less than 50% of those who suffer from a fall will tell their doctor
“Falls among adults 65 and older caused over 36,000 deaths in 2020, making it the leading cause of injury and death for that group.”(CDC, Older Adults Fall Prevention)
Many falls are preventable and, as mentioned above, approximately half go unreported. Providers can stay informed with predictive information about their elderly patients to anticipate falls and take action to keep our senior population healthy.
How to Stay Informed: Falls Risk Indicator
One source of information for providers to help fill this reporting gap is Emergency Medical Services (EMS) data on non-transport falls. To help address this issue, UHIN partnered with Utah’s National Emergency Medical Services Information System (NEMSIS).
UHIN ingests EMS non-transport fall information from NEMSIS and uses it in conjunction with patient age and past encounter diagnoses that have been reported to the CHIE to provide a yes/no risk assessment of a patient’s risk of falling in the short term. Utilizing the CHIE’s Falls Risk Indicator, providers receive timely information about potential falls within their patient population, empowering them to contact patients with the right support to keep them healthy and independent.
In addition to the Falls Risk Indicator, notification alerts include data pertaining to the patient’s condition and can include LACE scores to help caregivers prioritize care. LACE scores are industry indicators that assign a score on a scale of 1-19 assessing the patient’s risk of readmission. The score is a combination of the L:length of stay in a hospital (in number of days), A: acuity of admission, C: comorbidities, and E: emergency department visits in the last 6 months.
What is a Patient Event Notification?
Notifications about patients which physicians can receive as a file at their preferred frequency (real time, daily, weekly, monthly) by logging into MYUHIN or integrated into their EHR.
CHIE Alerts with Falls Risk Indicator and LACE Score
CHIE Alerts are automated electronic notifications informing providers about an event their patients have recently experienced. Admission, Discharge and Transfer (ADT) Alerts fill in the missing pieces necessary to manage patient care. The Falls Risk Indicator and LACE Score may be included in CHIE Alerts.
Providers opt-in to receive notifications because they’re an important component of continuity of care. Providers can identify the patients who require critical intervention and schedule follow-up appointments after hospitalizations. Notifications help prevent readmissions, improve care coordination and patient experiences. An additional benefit includes revenue integrity; by allowing providers to bill the appropriate level code, which may be of a higher value in instances of transition of care patients.
For Granger Clinic, CHIE Alerts helped their Transition of Care Management (TCM) team increase the number of patients identified as needing TCM from about one per week to an estimated 750 per month. Additionally, CHIE Alerts helped the Granger TCM team decrease readmission rates by 61%.
Payers that receive alerts can route patients into case management, which helps to reduce high emergency room department utilizations through increased visibility into member care activities and utilization trends.
Alerts can be tailored by type, such as inpatient, outpatient or emergency, and frequency based on needs and desires. Community providers and payers can receive notifications by subscribing to the CHIE Alerts service and providing UHIN with a panel of patients representative of the population for which they are providing care.
Click below to sign up to receive CHIE Alerts that include a Falls Risk Indicator and LACE Score.
Provider enrollment is crucial for health plans to ensure that members have access to a full range of services. Credentialing verifies a clinician’s training and licensing. Enrollment establishes the technical connection between the provider and the plan. The processes can be complex and time-consuming, but partnering with dedicated enrollment experts – like UHIN – can help streamline the onboarding experience and accelerate success in a highly competitive marketplace.
Why Enrollment Matters
Health plans are constantly looking for better ways to serve the insured, from developing innovative wellness benefits to making it easier to access high-quality, affordable care in the community.
Provider network development is a huge component of this quest for continuous improvement. Contracting with the right mix of providers – and enough of them – ensures that members can get a full range of services within an acceptable time frame.
Building this ecosystem isn’t always easy, especially when it comes to the nuts and bolts of bringing clinicians on board. Provider credentialing and provider enrollment are equally critical, yet they can often cause confusion and problems on both sides of the plan-provider relationship.
In fact, providers not being registered/credentialed with a payer is the #1 reason for denials. The #2 reason for denials: the provider did not complete the payer-required process for enrollment.
Both steps – credentialing and enrollment – are crucial. However, even the fundamental differences between the two activities aren’t always clear, especially because they bump up against each other during onboarding. It’s important to understand what’s involved in each process, how they work, and why finding the right partner matters so much to health plans as they grow and mature.
What is Provider Credentialing?
Provider credentialing is the act of verifying that a clinician has the correct training and licensing to practice in their area of expertise. It’s similar to an extensive background check. The process starts after a provider submits a request to work with a practice, health system, or health plan. Collecting this extensive dataset can take up to three months or longer.
While UHIN does not currently support the credentialing process, certain industry applications are in place, including the CAQH credentialing application. Until the credentialing process is complete, a provider cannot finish the rest of the enrollment process with a health plan. This is especially important for 98 percent of providers in the US who participate in Medicare and Medicare Advantage. In addition, nearly every health plan, including Medicare, requires EDI enrollment in order to start getting reimbursed for services.
What is Provider Enrollment?
Once a provider is officially welcomed into the network, the majority of health plans will require them to complete Electronic Data Interchange (EDI) enrollment, which is the technical connection between the provider and the plan. EDI enrollment allows providers to submit electronic claims to the plan and receive remittance for their services.
Electronic claims submission is nearly universal in the medical industry, according to the latest CAQH index report. In 2022, 97 percent of claims submissions transactions occurred electronically, giving both providers and health plans a strong motivation to ensure they are appropriately connected.
Unfortunately, neither the administrative nor the EDI enrollment processes are standardized across different health plans. This forces providers to juggle many different requirements and documentation requests for each individual payer. The complexity of managing requests from a slew of disparate plans and providers can lead to mistakes and omissions that extend the timeline.
Even more information may be required during EDI enrollment than credentialing. This can take an additional four to six weeks (or longer) on top of the credentialing timeframe. This is especially true if extensive contract negotiations are necessary or IT challenges get in the way.
In addition, smaller provider groups often do not have enough people-power to devote exclusively to enrollment, making it even more difficult for plans and providers to work together effectively.
UHIN’s Enrollment Team provides detailed next steps for enrollment based on each specific payer and transaction type for each case. Additionally, we provide defined next steps to move forward with enrollment, based on the payer requirements. UHIN can be reached at enrollment@uhin.org and we will be happy to provide enrollment direction, advice and helpful support through the EDI enrollment process.
How Can Health Plans Streamline Enrollment Processes?
Just like many other areas of the healthcare ecosystem, provider EDI enrollment can significantly benefit from digitization and strong partnerships with expert teams. The widespread lack of standardized processes means plans and providers have to consider each request as a one-off, which can take a great deal of time and effort to parse through without some help.
Charting a Course for Success
When working with providers, health plans should offer clear and detailed instructions on the information needed and the deadlines for delivering it.
Plans should assess their needs by charting out their existing enrollment workflow and identifying any bottlenecks that lead to lag time. Often, these pain points are related to delays in collecting information from providers and internal delays in processing paperwork once received. The result of these delays are wild swings in average completion time for provider onboarding, which creates unpredictability on both sides of the relationship.
Finding the Right Support
On the internal front, plans should seek out enrollment partners that can field provider requests on behalf of the payer, taking the task off the shoulders of health plan staff. It should take a specialist enrollment team less than one business day to process a request once all of the information is received. There may be additional waiting time depending on the unique payer requirements.
Health plans and providers should make sure they are working with a dedicated enrollment team that can take deep dives into problem-solving when unique technical or administrative challenges arise, such as a technology enhancement that can lead to the need for a process rewrite.
An experienced partner, such as UHIN, offers an expert enrollment team to help navigate the complicated enrollment process. Although we do not currently provide credentialing support, we have a proven history in expediting and accurately guiding providers through the enrollment process. Our enrollment team is based in the US and delivers in-depth knowledge and support to make the enrollment process as frictionless as possible. We can handle any questions you may have in this complicated and critical process.
Partnering with the Right EDI Enrollment Experts
Enrollment involves complex activities with many moving pieces. Getting them right is vital for the success of health plans and provider groups. By understanding the nuances of the process, plans and providers can start to tackle the pinch points that make network development so challenging. Plans that enlist the help of dedicated partners to take on key tasks, such as enrollment, have a better chance of creating a smoother onboarding experience and accelerating their success in a highly competitive marketplace.
UHIN’s enrollment team offers years of experience helping providers through the enrollment process. We provide direct support and in-depth knowledge to expedite the enrollment process and get providers over the finish line no matter how complex or unique the process may be.
Are you a current provider with a UHIN account and interested in learning more about enrollment? Contact enrollment@uhin.org or customer service at 877-693-3071.
If you’re new to UHIN, click below and tell us how we can help streamline EDI enrollment onboarding and relieve burdens for your health plan!
Clearinghouses are more than just utilities for moving claims from provider to payer. They are integral to improved healthcare interoperability and the quest to extract valuable insights from clinical and administrative data.
How Clearinghouses Help to Enable Interoperability
When talking about interoperability in healthcare, clearinghouses aren’t always the first thing that comes to mind. For many years, the conversation has been much more focused on the exchange of purely clinical data from one provider to another – a challenge that is still only partially solved even after decades of hard work.
While clinical data exchange is certainly vital to success for patients, health plans, and providers, it’s just the tip of the interoperability iceberg. Accurate claims data is equally important for making informed, proactive decisions about patient care.
Claims data doesn’t just offer deep insights into everything from overall provider performance patterns and to an individual’s ability to engage with their care plan. It’s also essential for the day-to-day business of being a payer: reimbursing providers for the wide variety of services aimed at improving member health.
Clearinghouses are the technology that makes this all possible. By coordinating the secure flow of claims information between providers and health plans, clearinghouses quietly and steadily keep the $4.3 trillion healthcare industry humming along.
It’s easy to look past this type of “middleware” solution, especially when it works well enough to avoid causing any major issues. But skipping over clearinghouses during the interoperability discussion would be a mistake, especially as payers and providers start to engage with increasingly complex, unstandardized data sets and new types of clinical and financial partners in a more patient-centered, value-based environment.
It’s time to take a closer look at the clearinghouse as a fundamental enabler of trusted interoperability between trading partners and ensure that both payers and providers are maximizing the value of what these important platforms can do.
The Crucial Role of Clearinghouses in Healthcare Operations
Every year, healthcare providers submit hundreds of millions of claims for patient services to thousands of health plans across the nation.
Just building the electronic pipelines to shuffle all this data back and forth each day is a monumental task. Making sure that the information is accepted and processed in a standardized manner, correctly integrated into a health plan’s internal reimbursement systems, and returned to the provider in a timely manner with the right payment – or a clear explanation for denial – is even more challenging.
Clearinghouses work in conjunction with electronic billing software to handle these processes digitally, proactively identifying common data integrity issues that may result in a denial or delay. Once a provider generates a claim using the standard 837 claim format, the clearinghouse accepts the file, scours it for any obvious errors, and sends it on to the correct health plan if it passes all the checks.
The plan then conducts further analysis for clinical and administrative suitability of the claim and makes a decision on whether to reimburse as requested, deny outright, or ask for clarification.
The more sophisticated and trustworthy the clearinghouse, the less work has to be done on each side of the partnership. Robust clearinghouses with more automation, advanced analytics capabilities, and a trusted position within the health IT community are associated with lower overall denial rates and higher first-pass success rates, which is good for providers, as well as reduced administrative burdens on the payer side.
The American Medical Association estimates that electronic clearinghouses can reduce the cost of claims processing by approximately 60 percent compared to similar paper-based workflows, freeing up time and capital to devote to other clinical or operational priorities.
According to CAQH, transitioning to fully electronic transactions could save the industry up to $25 billion per year, or 41 percent of annual spend in 2022.
Using Clearinghouses to Create a Network of Networks for Better Claims Data Exchange
A single clearinghouse cannot work in isolation, because health plans don’t just receive claims from their established, contracted in-network providers. They also get claims from an untold number of out of network clinicians from anywhere in the country.
This can be challenging on several levels. First, reimbursement rates and requirements are different for these partners. Second, out-of-network providers may not be familiar with the correct formatting and data requirements necessary to get their claims adjudicated quickly. And third, without being directly connected to the prospective payer’s proprietary clearinghouse, these providers must simply trust that hitting “send” on their claim form will result in getting that information where it needs to go.
This is where the right clearinghouse solution can take interoperability to the next level. Clearinghouse vendors must work with their peers, trading partners, and competitors to ensure that all claims, no matter their origin, are routed to the appropriate recipient with as few gaps and errors as possible.
Data standards like ASC X12 Version 5010 make it possible for clearinghouses to assemble into “networks of networks” and make certain that any provider can reach any payer whenever necessary.
Fortunately, the ASC X12 standard is well established in the electronic data exchange community, and claims are typically highly structured documents with relatively few unknowns, making it easier for clearinghouses to engage in the type of interoperability that is often so elusive in the clinical data ecosystem.
Trust as the Bedrock of Interoperability Between Payers and Providers
With trillions of dollars and huge volumes of sensitive clinical data shooting across the claims superhighways at any given moment, it’s essential that all parties involved have full and complete trust in their clearinghouses.
Choosing a clearinghouse with a strong reputation for security, service, experience, and responsiveness can turn an oft-overlooked piece of the interoperability puzzle into a valuable and proactive partner for improving clinical care and administrative efficiency.
A prospective clearinghouse solution provider should be able to demonstrate its mature and wide-reaching connections with peers across the industry to foster seamless interoperability for both in- and out-of-network claims. Platforms should also include process enhancements such as tools to generate cleaner claims, timely provider notifications at key steps in the process, and helpful resources to address any provider questions or problems that arise before or during claims submission.
With a trusted and collaborative clearinghouse, health plans and providers can work together more efficiently and effectively to accomplish their daily tasks while moving into the optimal position to take advantage of everything that rich, robust claims data has to offer.
Clearinghouses shouldn’t just feel like part of the furniture. Instead, they should become an active and integrated part of a health plan’s larger interoperability goals. By simplifying and streamlining the claims submission process, clearinghouses don’t just save time and money for payers. They can also unlock the full potential of claims data for broader financial and clinical analytics purposes, such as provider performance monitoring, population health management, and other high-priority value-based care activities.
