“Our life is March weather, savage and serene in one hour” (Ralph Waldo Emerson)
Such was life in the healthcare information technology sector this month. We collectively faced daunting cyber circumstances and peered into an optimistic future filled with the possibilities of A.I., resilient and redundant networks, and healthcare interoperability for all.
Spotlight
Our Response to the Change Cyber Incident
UHIN is dedicated to maintaining interoperability for all payers, providers and partners. When an event as large as the Change Healthcare cyber incident impacts our community, we know we need to serve as a bridge to stable ground. Read more about the actions we’re taking to support our community at this time.
We’re actively supporting Providers by expediting enrollment with Payers to get claims flowing again. Providers can leverage our solutions to create and send professional and institutional claims, submit via SFTP, file tool or online hand-entry, check claims status, manage denials and rejections, and search, view, and download payment information.
We can connect with health plans, so they may receive claims from providers through a direct connection to our clearinghouse. Empower your provider network by elevating your collaboration efforts, securely sharing information and data, and providing better affordable care for your members.
The alarming rise in cyber threats – namely ransomware – highlight the urgent need for enhanced cyber resiliency and robust security measures in healthcare. Read our recent blog post with five ways to reduce your risk and secure personal health information (PHI) from cyberattacks.
HIMSS shared their recap of the 2024 Global Health Conference & Exhibition (March 11-15 in Orlando). Cybersecurity, A.I.,and health equity and access to care delivery were big themes this year. What were you most excited to learn at HIMSS this year?
We’re preparing a series of online trainings for CHIE users this year. Explore our new platform and share feedback with our HIT experts. Stay tuned for updates on upcoming trainings.
Wrapping Up
Thriving in Complexity from the Comagine Health Blog
Comagine Health President and CEO Marc Bennett addresses how the organization has been managing competing tensions while building partnerships to serve as a prime contractor for the 13th Statement of Work in the Midwest CMS QIN-QIO Region 6.
UHIN is dedicated to maintaining interoperability for all payers, providers and partners. When an event as large as the Change Healthcare cyberattack impacts our community, we know we need to serve as a bridge to stable ground.
In response to the incident, UHIN immediately disconnected from Change Healthcare’s platform to prevent potential harm. We also conducted a detailed review of our internal systems, confirming no impact on our network. UHIN continues to communicate with Change Healthcare and United Health Group to receive the latest updates and guidance.
UHIN is currently retaining any claims submitted after February 21, 2024, that are intended to be delivered to Change. These retained claims will be processed through our system and sent to Change once it is safe to re-establish those connections. The restoration timeline is being updated by UnitedHealth Group here.
For providers, you need to get your claims flowing again. We are working with payers to expedite your enrollment with them. You can then create and send professional and institutional claims, submit via SFTP, file tool or online hand-entry, check claims status, manage denials and rejections, and search, view, and download payment information. Most electronic health records systems have configuration capabilities to securely connect with UHIN’s systems. Sign up to fast-track your enrollment with many payers today, and manage your claims and revenue with assurance.
For health plans, you can receive claims from your providers through a direct connection to UHIN. We support enrollment for your providers, just as we’re currently supporting fast-track enrollment for the payer list below. Empower your provider network by elevating your collaboration efforts, securely sharing information and data, and providing better affordable care for your members.
Thanks for spending this extra day going around the sun with us. In February, we dove into the 2023 CAQH Index Report and prepared for the CHIE’s migration to a new platform.
One more thing: For our providers experiencing disruptions in their claims management due to the Change cyberattack, we’re here to help. Please contact us to fast track your enrollment with payers at customersuccess@uhin.org.
Spotlight
Black History Month and American Heart Month
In February we recognized Black History Month and American Heart Month. Here are just a couple ways to support and celebrate these causes throughout the entire year:
For health care professionals and clinicians, use the resources in the Center for Disease Control (CDC) heart toolkit to support their patients, especially women, by listening to their heart.
In Utah? Dive into Utah’s rich black history at the Utah Black History Museum! Find the mobile exhibit across Utah this year or consider donating.
HIT News
The CHIE is Moving to a New Platform!
The new platform empowers CHIE users to better understand patient populations, provide greater care, reduce waste while improving quality, and pinpoint at-risk patients to intervene before their next encounter.
After consulting with our community’s advisory committee, we will be migrating five years of data with the exception of opt out consents, immunizations, allergies, and colonoscopies for which a longer history will be migrated.
Technical implementation is currently underway and we anticipate user migrations will start in Q2 of 2024. We will keep all CHIE users informed of our progress via email.
We published two blog posts sharing our thoughts on the most recent CAQH Index released earlier this month. How did electronic transaction adoption and healthcare administration change in 2023 for both providers and payers? Keep reading to find out.
Our CEO, Brian Chin, recently attended ViVe 2024. Artificial Intelligence was a hot topic this year, as you may have expected. Check out a few photos from the conference here.
Are you going to HIMSS 2024? Let us know what you’re most excited to see while in Orlando next month at communications@uhin.org.
Trainings and Webinars
CHIE platform trainings
We have online trainings coming up for the new CHIE platform. Please sign up for CHIE updates and our Events notifications to add these to your calendar so you don’t miss a thing!
Wrapping Up
Share your story, plus looking ahead to March
Do you have something your peers in healthcare and tech just have to know about? 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.
Next month we’ll attend HIMSS 2024 and help to raise awareness of the risks and symptoms of diabetes on American Diabetes Alert Day (March 26).
Join our monthly newsletter and don’t miss anything!
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
Question 4: How Does Your EDI Partner Reduce the Burden of Claims Submission for Providers?
Plan members want access to a range of high- quality providers. Without a robust provider network, health plans are challenged to grow membership and differentiate themselves from competitors.
The Council for Affordable Quality Healthcare (CAQH) 2022 Index reported that providers spend ten minutes submitting a single electronic claim on average. For paper, it’s 22 minutes. A large part of this is repetitive data entry. These time blocks add up to significant resource drains in a typical day. Alleviating stressors will reduce payer-provider friction and promote cooperation in your common goal to improve health outcomes for members.
With the right EDI partner, you can streamline operations, reduce administrative burden, and improve your organization’s bottom line. Embracing new technologies and cooperative partnerships can help you gain a competitive advantage and, ultimately, provide better care to members.
Our fourth and final question leads you to ask yourself: “Is my EDI partner providing holistic support to my partner’s and my own organization’s operations?”
Ready to jump to all four questions? Want to see how your EDI partner stacks up? Download our white paper here.
How Does Your EDI Partner Reduce the Burden of Claims Submission for Providers?
Plan members want access to a range of high- quality providers. Without a robust provider network, health plans are challenged to grow membership and differentiate themselves from competitors.
The healthcare industry is becoming more consumer-driven and labor shortages continue to mount. Health plans need to be mindful of provider relationships and the administrative burdens your claims processing may be placing on them.
The Council for Affordable Quality Healthcare (CAQH) 2022 Index reported that providers spend ten minutes submitting a single electronic claim on average. For paper, it’s 22 minutes. A large part of this is repetitive data entry. These time blocks add up to significant resource drains in a typical day. Alleviating stressors will reduce payer-provider friction and promote cooperation in your common goal to improve health outcomes for members.
Your healthcare EDI partner should help you to help providers with an affordable billing tool. Our solution, MYUHIN, reduces repetitive data-entry, and solidifies coding and submissions data to satisfy your processing requirements. Providers can use MYUHIN to submit claims, check patient eligibility, and search, view, and download payment information from any computer, any where.
UHIN is a national EDI network built in 1993 by health plans. We partner with payers and providers across the US. Our approach to EDI and customer service is different. If you’re interest in learning more, please contact us today.
Question 3: Are Providers Frequently Contacting You With Questions About Their Claims?
Health plans constantly seek to optimize their high-performing provider networks which provide value to members and patients. To grow these important networks, payers should nurture their provider relationships through personal attention and cutting edge technology.
This is particularly important at a time of mounting staffing shortages and rhetoric of economic downturns. Additionally, medical claim volume increased by 28% in 2022 as vaccines became available, medical offices reopened and pandemic regulations softened. When you add this up, the need for administrative simplification becomes more obvious for health plans and providers.
Tracking down claims, managing denials and submitting myriad claims can burden staff, compound labor costs and decrease profitability. When your provider network is stressed then your ability to grow as a carrier is impacted. Your EDI partner should automate workflows and manage your trading partner network so your support staff can focus on more strategic priorities, rather than answering phone calls and emails all day long.
Our third question addresses this concern as you ask yourself, “how does my EDI partner stack up?”
Ready to jump to all four questions? Want to see how your EDI partner stacks up? Download our white paper here.
Are Providers Frequently Contacting You With Questions About Their Claims?
When resources are tied up managing claim inquiries, you’re likely underperforming your peers and weakening your organization.
An inability to provide visibility to track and troubleshoot claims in a timely fashion can create financial implications. The increased demand on staff can decrease productivity, which could further delay payments and lead to staff burnout and turnover. Payers must respond to providers within a regulated timeframe, and providers rely on prompt payment for cashflows and their own business growth. Further dissatisfaction amongst providers and members can upend the collaborative nature of interoperability and could drive providers and members away to different plans.
The volume of inquiries to track down claims can burden staff and compound labor costs through the need to hire additional people. The situation can foster negativity between providers and operators, reducing satisfaction for both groups. Your EDI partner should work with you to increase your ability to automate claims processing. Part of this is facilitating a simple, electronic process for providers to submit their transactions and understand the status along the way.
UHIN is a national EDI network built in 1993 by health plans. We partner with payers and providers across the US. Our approach to EDI and customer service is different. If you’re interest in learning more, please contact us today.
Question 2: Can your Clearinghouse validate claims? Can you customize validation to your needs?
Claim validation should be par for the course. Still, many clearinghouses cannot properly validate claims. Much less, health plans are left unable to customize settings that allow for certain transactions while rejecting others. This leads to decreased adoption of auto-adjudication and on-going manual intervention that increases costs and decreases productivity.
SNIP Validation is a common solution for EDI data validation and compliance. There are seven (7) SNIP types and each health plan can tailor type settings to their needs. The right EDI partner works with their health plans to ensure the types are appropriately calibrated and implemented.
This leads to the second question to ask when wondering, “how does my EDI partner stack up?”
Ready to jump to all four questions? Want to see how your EDI partner stacks up? Download our white paper here.
Can your Clearinghouse validate claims? Can you customize validation to your needs?
Ensuring claims are HIPAA compliant and in a valid EDI format before they enter your system is key to streamlining the claims process.
Effective validation reduces administrative workload, mitigates risk of non-compliance, and helps avoid wasted time and provider appeals. SNIP Validation is an important step for pre-adjudication, scalability and profitable growth. Every plan operates at a different level of preparedness. One health plan may be working toward full automation, while another might seek to relieve staff burden to focus on other initiatives. Depending on your systems and goals, an EDI partner can support and modify the validation set-up to support your strategic needs.
SNIP Types
EDI Standard Integrity Testing: Validates the basic syntactical integrity of the EDI submission.
HIPAA Balance Testing: Involves ensuring that amounts reported in different places add up correctly.
HIPAA Inter-Segment Situation Testing: Testing of specific intersegment situations described in the HIPAA implementation guides.
HIPAA External Code Set Testing: Testing for valid implementation guide-specific code set values, as well as other code sets adopted as HIPAA standards.
Product Type/Type of Service Testing: Ensures that the segments (records) of data that differ based on certain healthcare services are properly created and processed into claims data formats.
Trading Partner-Specific Testing: The Implementation Guides contain some HIPAA requirements that are specific to Medicare, Medicaid, and Indian Health.
UHIN is a national EDI network built in 1993 by health plans. We partner with payers and providers across the US. Our approach to EDI and customer service is different. If you’re interest in learning more, please contact us today.
Question 1: Why are you with your current EDI vendor?
Health plans are often led to believe that healthcare electronic data interchange (EDI) vendors and Clearinghouses are utilities. Just a means to an end. It’s true that utilities – such as water – and EDI vendors both follow regulated protocols and move standardized, secure things.
When you turn on the faucet in your kitchen or bathroom, you expect clean, clear water delivered immediately and at your desired temperature. Often it works perfectly. However, you don’t typically choose where the water comes from or the company who provides water to you. You don’t adjust your settings at an infrastructure level and underlying delivery issues may be well beyond your control.
As a health plan, you can select your EDI vendor, enhance your provider network, adjust settings at an infrastructure level, and get ahead of underlying issues. Beneath the surface, health plans can work with expert EDI partners (not just vendors) to navigate turbulent waters together and deliver seemingly fluid experience and impactful outcomes. This process is understandably daunting despite the increased adoption of automated processes.
For this reason, health plans should ask four key questions to understand the value that their EDI vendor is bringing to the table. Our next four blog posts will cover these four simple, yet critical questions for health plans:
With many options out there, why are you with your current EDI vendor? Are they just a vendor in your tech stack or do they serve you as a partner should?
Can your Clearinghouse validate claims? Can you customize validation to your needs?
Is your provider network frequently contacting you with questions? How does this impact your staff, strategy and budget?
How does your EDI partner alleviate the burden of claims submission and simplify your administrative workflow?
Ready to read all four questions now? Want to know how your EDI partner stacks up? Download our white paper here.
Why Are You With Your Current EDI Vendor or Clearinghouse?
Our first post is introspective. We’ll look at the reasons you may be with your current Clearinghouse or EDI vendor, and how they should serve you to meet the strategic objectives of your department and company as a whole. Keep reading about the way it’s always been, and the futurist approach that health plans should take with a key strategic EDI partner.
The Way Clearinghouses Have Worked
Healthcare EDI networks have been built on vendor relationships that can be daunting and confusing, despite best intentions and the increased adoption of automated processes. Vendors offer “sticky” solutions that can entangle health plans with complicated agreements, abrasive onboarding processes, and technology that may not provide meaningful value.
Today, the essence of a partnership can get lost in the complications of healthcare EDI management. We can shift this paradigm by remembering we’re all in this together – from payers to trading partners, and providers to patients.
So, What Keeps You With Your Current Clearinghouse?
Does your partner simplify administrative burden? Do you have visibility into transactions? Do you receive timely, expert guidance on future X12 standards and HIPAA compliant transactions? An EDI partner should be focused on your holistic operations, and not merely transactions (though they should do those well, too). Perhaps it’s time to rethink the status quo.
If your EDI vendor is not serving you as a partner, you may want to consider what this relationship is costing you.
UHIN is a national EDI network built in 1993 by health plans. We partner with payers and providers across the US. Our approach to EDI and customer service is different. If you’re interest in learning more, please contact us today.
Health plans could save billions each year by accelerating administrative efficiencies for themselves and providers. A new CAQH report breaks down the opportunities and showcases the value of a clearinghouse partner as electronic data interchange (EDI) becomes the norm. Working with a trusted clearinghouse partner – one who knows the complexities of today and tomorrow – will help you navigate the future.
A Decade of Success Reporting on a Digitally Enabled Administrative Environment
Administrative transactions, including benefit and eligibility checks, prior authorizations, and claim processing, form the backbone of the entire healthcare system. Health plans and providers must be able to conduct these EDI transactions in a swift, secure, and standardized manner to enable delivery of timely and informed care.
CAQH, a non-profit alliance of health plans and their partners, has tracked adoption of electronic transactions every year since 2013. The most recent edition chronicles a decade of commitment to digitizing administrative processes and strengthening EDI connections between disparate systems in the payer and provider environments. The adoption of many electronic transactions has increased, such as claims submissions, eligibility and benefit verification, and acknowledgements.
Automation is the key to getting it right. Throughout the past decade, the use of EDI has skyrocketed by 25 percent, according to the latest edition of the CAQH Index Report. Now, nine out of every ten transactions take place digitally, reducing industry-wide operating costs by approximately $187 billion every year.
Despite this progress, there are still opportunities for health plans to control costs, maximize resources, and trim the time it takes to conduct the business of healthcare. Certain critical processes have a long way to go, like prior authorization and attachments.
Currently, only 28 percent of PAs are being exchanged digitally while the electronic submission of attachments that support medical claims is similarly low, starting at 6 percent in 2016 and only rising to 24 percent by 2022.
During the coming years, health plans will need to reexamine their current workflows to boost the use of digital strategies for sharing documents and data with their provider partners, particularly as transaction volumes have risen 28 percent since the COVID-19 pandemic, paired with a 47 percent increase in overall medical spending.
Experienced and trusted clearinghouses will be central to success. Clearinghouses make it simple for plans and providers to share information and collaborate around patient care, creating the right environment for the smooth and seamless exchange of vital administrative data.
Uncovering Opportunities to Reduce Burdens in Key Administrative Areas
The positive results so far have saved hundreds of billions for health plans, as well as an average of 14 minutes per transaction for medical care providers. But addressing these notable areas of opportunity and transitioning fully to EDI could produce a further $25 billion in cost reductions, representing 41 percent of the current spend.
Specifically, health plans can focus on the following areas to trim their budgets and provide relief to payer and provider staff members:
Eligibility and benefit verification: Representing the highest proportion of annual spend, health plans could save up to $12.8 billion if they work with providers to digitize the 10 percent of transactions that remain manual. Closing the gap will be crucial for sustainability as the volume of transactions continues to increase.
Prior authorizations (PAs): A well-known pain point across the industry, PAs are time consuming and complicated to submit manually. The medical industry could save close to $450 million per year by creating more automated and streamlined PA processes, not to mention trimming 11 minutes per transaction off of a provider’s daily calendar.
Claims submissions: As the volume of medical services increases, so too will the claims for reimbursement, adding to the $11.1 billion industry spend. CAQH points out that training staff to conduct electronic claims submissions can take time and money, so beginning the adoption and education process now, before volumes exceed current norms, will be important for achieving savings and maximizing staff productivity.
Attachments: Supporting information for reimbursements is rarely sent electronically, creating a $213 million annual savings opportunity. CMS recently proposed standardsfor these transactions to help guide adoption and simplify data exchange.
Claims status inquiry: Payers and providers are spending 50 percent more on claims check ups as margins remain slim following the pandemic. Broadening the automation of claims status updates could help the industry save $3.6 billion a year, plus 15 minutes per transaction for providers. A clearinghouse solution with automated features can help to achieve this goal for plans and their partners.
Remittance advice: Similar to claims status inquiry, automating the delivery of remittance advice could save medical care stakeholders up to $2 billion a year by increasing efficiency and reducing time spent on phone calls and follow-ups.
Capitalizing on these transactions to reduce spending and staff burdens will be important for health plans as the volume of medical transactions is expected to continue to increase.
While there are small spending increases associated with adopting digital transaction tools, the savings far outweigh the required investment, CAQH states. Automating these processes can produce further cost reductions by avoiding the need to attract and retain larger workforces, especially as qualified staff are now in short supply.
Leveraging Clearinghouses to Achieve Administrative Efficiency
Clearinghouses make all of these transactions possible, so health plans will need to evaluate their existing capabilities, and find the right partner, if necessary, that offers a tested and sophisticated approach to automation if they wish to take advantage of these savings opportunities.
Plans should look for clearinghouse solutions that have deep experience and an exceptional reputation for reliability, agility, and standards-based collaboration between disparate trading partners.
Health plan leaders should also conduct thorough internal reviews of their established workflows – and work closely with their contracted providers to understand their processes and frequent problems, too – in order to identify potential areas of improvement. Next, they should seek out a clearinghouse partner with capabilities to fill in those gaps and accelerate savings in time, staffing, and operational spending.
By adopting more modernized digital clearinghouse solutions with the capacity to streamline communications and complete tasks in a quick and trustworthy manner, health plans can begin to take advantage of everything that EDI has to offer.
Preparing for the Future of EDI
In just a few years, plans that proactively embrace electronic transactions at scale can position themselves for significant cost reductions, fewer burdens for staff, and better administrative experiences across the entirety of the care continuum.
The right clearinghouse partner will proactively work with plans to develop a tailored roadmap to greater EDI adoption, help staff to maximize their productivity in this new ecosystem, and stay on top of evolving federal regulations guiding the evolution of electronic transactions.
With a 30-year history of helping health plans accelerate the adoption of electronic transactions, UHIN has been instrumental in creating a more cost effective, less burdensome future for critical information exchange. Our experts meticulously evaluate the needs of each of our partners and work with leaders to create a customized plan for expanding EDI activities with an eye toward improving efficiency across the enterprise.
As more and more administrative transactions go digital, health plans can’t afford to be left behind. Get started today with a consultation with our experienced team.
