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.
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!
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.
Are you really, truly ready to grow in 2023? Using MYUHIN Templates and Drafts could help your clinic or private practice save time, ease administrative burden, improve cash flow and grow now.
Templates Put You Closer to the Finish Line
Providers spend as much as 10 minutes submitting one electronic claim – and 22 minutes for paper! (2022 CAQH Index) Seemingly small, ongoing hurdles, like repetitive data entry, can impede your growth. Save time in 2023 by creating claim Templates that you know will work! Create one claim, one time, then use it over and over again. Why start from scratch when you can start only a few clicks away from the submission finish line?
Submit your claims even faster and stay on top of your practice’s billing by leveraging our lightning-fast submission process. If you’re working long hours to get your work done in a timely manner, you can reclaim your time, finish work faster and decrease stress. We’ll keep you informed as your claim makes its way from submission to payment.
You can set up your template for your unique circumstances. Everything in the claim form can be configured, except for:
Patient Name
Date of Service
Take Control with Drafts
Ever been distracted and have to get up from your claim mid-submittal? How many times have you been close to completing a claim only to find that you still need key information to complete it? MYUHIN’s Drafts tool to the rescue!
Using our Drafts tool, you can start your claim, save your progress (Drafts), step away, then come right back to where you were in your workflow. It’s easy to save your progress with the Drafts tool: Just click save as Draft, then pick up where you left off without losing any of your existing work. No more sticky notes or notepad scribbles!
Clinics, private practices, and billers use MYUHIN everyday to check eligibility and submit claims to our national network of payers. You can access MYUHIN from any PC or Mac connected to the internet (no software installation necessary). MYUHIN is an intuitive tool that enables anyone, so you won’t need hours and hours of training to get the job done. Everything just falls into place for you.
We hope you’re ready, because everyone is counting on YOU!
