With the PPACA Changes, the Bill Is Not in the Mail

Push from regulators is for wider use of e-billing

There are many theories circulating among the various workers’ compensation blogs, newsletters, and websites regarding the impact that the Patient Protection and Affordable Care Act (PPACA) will have on the industry. Often mentioned is that the need to make provider and payer interactions more efficient is a resounding theme throughout the set of new regulations. Medical billing and the ultimate reimbursement processes have become a particular focus by the American Medical Association and numerous regulators.

The workers’ compensation world has long been regarded as one of the last holdouts to the continued utilization of paper bills, checks and explanations of reimbursement (EOR.)  The rationale emanates from the nuances of workers’ compensation, including specific data elements (like claim numbers), attachments, and jurisdictionally required payment-reason codes. Even though many payers have invested in technology to create paperless claim environments, most continue to use paper conversion processes and print/mail facilities for check/EOR output. In essence: paper in, paper out.

What would be the impact if the majority of the paper flowing into and out of a claim operation could be avoided? Workers’ compensation professionals can look toward the group health claims world for the answer.

Group health deals with much higher volumes of medical interactions and has been migrating away from paper for years. It is common practice for providers to send—and payers to receive—a high percentage of medical bills electronically and then process reimbursements via Electronic Funds Transfer (EFT) and electronic remittance (ERA) information. A framework of connectivity between providers and payers has been evolving over many years, and the PPACA now is placing an emphasis on full utilization.

The workers’ compensation industry has been dabbling in the use of medical bill/attachment EDI submission since about 2000. It began with a few early payer adopters and some provider groups that mainly support occupational health services. However, two catalysts may now accelerate e-billing: The explosion of the Internet and evolution of personal computers has put the tools to deal with such things as attachments on the desktop of providers; regulations, both state and federal, are pushing the process.

Several States Lead the Way

Intuitively, both regulators and claim professionals have for some time recognized the potential impact taking paper out of the system could have on both operating costs and improved coordination. Texas was the first jurisdiction to require workers’ compensation e-billing in 2008. Next was Minnesota in 2009 as part of an overall EDI mandate. California has now promulgated rules that go into effect in October 2012. Illinois and North Carolina have included e-billing as part of recent reform legislation. Several other states are in various stages of e-bill rules creation/adoption. In the 2011 Florida CFO Biennial Report, the Three-Member Panel made as its top recommendation that the Florida Division of Workers’ Compensation develop an action plan by 2015 for the creation of e-bill rules.

Today some of the largest national and regional payers and provider groups are making e-billing a standard part of their business operations, even without state mandates. The primary reasons are the gains in efficiency and coordination for both providers and payers. According to Kim Haugaard, vice president of network and medical operations for Texas Mutual, which began e-billing in 2008, “E-bill penetration continues to rise and related automated processing has lowered the turnaround time for payments by 33 percent. From the outset, Texas Mutual’s compliance with e-bill regulations has been critically important in terms of reinforcing our market leadership and establishing an operationally efficient model under the industry’s first e-bill regulatory framework,” Haugaard says.

The occupational medical community is also realizing the benefits of the linkages and insisting on all payer-access solutions. Greg Gilbert, senior vice president of reimbursement and governmental relations for Concentra, Inc., a national occupational healthcare supplier that has been e-billing for many years, says, “Concentra has seen an improvement in over 15 days in payment cycles, and communications with the claims staff is timelier.”

Others Say, "Give Me a Reason"

Despite these and other organizations’ reported successes, widespread adoption remains spotty. The reasons vary. Some organizations are holding off “until the state tell me I have to.” Others cite resources or technology challenges. (Interestingly, most commercially available workers’ compensation bill review services or platforms possess the capability to transact electronically today.) Others express concern that any change to operating models could have a financial impact on either expenses or claim costs, or both. (Industry analysts for some time have stated that a formidable factor in controlling medical severity is access to timely and accurate treatment data.)

With the overall medical delivery system focusing on full utilization of EDI methodologies, and with workers’ compensation only a small slice of the whole system, whether by mandate or voluntarily payers and providers need to address this topic. Additional state and federal mandates will only expedite and expand the necessity of the workers’ compensation industry to embrace these tools. So why not get started now?

Don St. Jacques is senior vice president–COO of Jopari Solutions, Inc., a nationwide provider of workers’ compensation e-billing services for providers and payers. He will be part of a panel at the Aug. 21-24 Workers’ Compensation Educational Conference in Orlando entitled “Electronic Billing for Healthcare Providers: An Idea Whose Time Has Come, (Or Is It Already Here and You Just Haven’t Been Invited to the Party)?” 

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