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Meeting Mandates, Making the Connection:
Workers’ Compensation Electronic Health Care Transactions
November 5, 2014
About the notes in this document:
During the symposium above, four simultaneous smaller group discussions were conducted to help identify and address challenges and possible solutions to workers compensation electronic health care transactions. The note-taking on the flip charts during the discussions was intended primarily to help quickly capture high-level comments, points, or questions, but was not intended to capture the full extent and depth of the conversations. Following the symposium, MDH and DLI staff typed up the notes and, as requested by some participants, are making them available to symposium attendees with the acknowledgment that they are likely a helpful, but self-limiting, incomplete record. In addition, the following notes should not be construed as representing the views, positions, or policies of the Minnesota Department of Health (MDH) or the Minnesota Department of Labor and Industry (DLI).
The first line of notes under each category is what the group discussed in Session #1. The Second indented information reflects solution suggestions, which were given in both Session #1 and Session #2.
1. Patient Registration and Care
Patient does not know/state it is Work Comp when they present.
o Need to ask patient at Registration if it is a Work Comp related visit.
Claim #s do not match
o Need to ask at Registration if this is a new claim or a reoccurring visit for previous Workers Comp claim – so get correct #s.
Claims being billed without all the correct information, because the correct information is not collected at Registration.
o Some Vendors setting up Work Queue for Workers Comp so it doesn’t go ‘out the door’ to bill until attachment and all information is accurate.
Issue of wrong Payer ID on claim. Often worksites use a different payer for work comp claims than general health claims (or an intermediary insurance payer for work comp). Also, different worksites may a different Payer ID for the same Payer, so need the worksite’s address. For example, McDonalds’ in one location may be a chain and have one payer ID for the workers’ comp insurance, but another McDonald’s is independent and may use the same insurance company, but has a different payer ID. So need Worksite name, address, and correct Work Comp insurance payer information.
o One Provider giving all Work Comp patients an information packet at
Registration to be completed by the employer and faxed to the provider and the bill is held until this is received, or after providers’ max days (5-7), the patient is billed – usually this will get a response in a timely manner.
o Would like one payer ID per Payer – is this possible?
Issue of payer ID associated with a different company name than the Common Company Name. Discussion of which ID to use throughout process – Payer ID, Tax Payer ID, or
Page 2 of 5 OEID. Currently Payer ID is set up by Worksite Employer ID. Need to move to 837 version that supports down to the worksite address to identify Payer ID.
o Bring Payers together to identify best ID to use, and which field to put this in. Suggested the clearinghouse would put the number in that field.
o Some providers will ask patient at Registration for the name of the company on their paycheck.
o State Department should add the Payer ID.
o Claim number (needs to be used, and matched, at clearinghouse), DOB, Date of Injury, Patient Name, and Payer ID used for claim identification. Need rule about which ones and how many are required for matching.
Need a ‘best practice’ for front desk Registration staff. o Need patient Education on process.
Issue of needing vendors/providers to clean up Master File, using synonyms when two different names are used commonly for the same worksite or payer. The systems do not have the accurate payer IDs, as they change.
Would like Point of Contact information for patient – to be able to tell them what is covered by Worker’s Comp and what is not covered by Worker’s Comp – at the time of Registration.
Sometimes patient does not tell Registration staff that the visit could be Worker’s Comp related, so a general health claim is filed. Patient files a Worker’s Comp claim a few days later, and provider doesn’t find out until the initial bill is declined.
Lack of compliance to electronic billing requirement because it is easier to get the claim by sending paper than trying to figure out what happened to the claim.
2. Create e-bill (837), attachments
Pharmacy (and other Specialists) get e-prescription (or referral for MRI, provider follow-up) but are not informed that the visit is to be covered under a Worker’s Comp claim (or given the claim number), so they are filling bills under patient’s general pharmacy insurance card only to get denied and have to seek information from initial health source and rebill. This is a very manual process.
i. Need indicator on e-script message if Work Comp visit so will be correctly billed (no co-pay) the first time.
Attachments are not ready until health care providers have completed chart notes – each provider system needs to identify if they will 1.) hold the bill for a completed attachment, link the two and send together, or 2.) send the bill to a clearinghouse, which will hold the bill until the attachment is sent (sometimes by a different system of the provider), and the clearinghouse links the two and sends to the next clearinghouse or payer.
It can take >75 days to find out whether a charge is covered or not by Worker’s Comp, or that it used to be, but has changed, so provider has to rebill.
Page 3 of 5 i. Need tracking system to identify where each claim is.
Claim number rules of are different between ClearingHouse(s) and providers. X-12 transaction specifies 50 character maximum, with no specifics on alpha/numeric. Some provider (or clearinghouse) system require specific alpha/numeric or >50 characters, so systems can’t respond, and claim is denied. Need one set of rules for claim numbers.
Providers drop bill to paper for Worker’s Comp because it takes too long to get bill paid, and too much work to identify what, or where, the issue with the claim is.
3. Send e-bill (837), attachments
Clearinghouse(s) asking for provider vendor to help clean the initial claim, to limit the initial denials.
No standard for claim matching and matching criteria. The name is often not a match. Clearinghouse uses claim number, but 3rd party system doesn’t have the claim number, so provider can’t find out what happened to initial claim.
i. Need standard format for attachments (CCDA, TIF, PDF, EXL, etc.)
ii. Need standard transmission methods for 275 and EDI to carry the formatted messages.
Difficult to identify who to talk to for resolving electronic claim issues.
Not all payers are excepting claims, even though it is legislation. Need enforcement.
837 requires SSN with a field value – provider may not collect SSN as an identifier, or patient may not choose to give SSN, so need to identify standard value that would be allowed by all clearinghouses/payers so if the rest of the claim is clean, it will be processed. Some are using 999 in unknown SSN, but others don’t accept this. If SSN is blank, bill is rejected.
i. Need MN to identify default value for SSN or make SSN optional in X-12. 4. Received e-bill (837) attachments
Some systems not able to link attachments to the bill (at provider or clearinghouse level).
Difficult to find out where problem is. Takes a lot of time, sometimes need to open tickets with multiple payers/clearinghouses, and each do not have same information to be able to track down the claim.
5. Acknowledgement (receipt of bill – TA1, 999, 277CA)
277AC needs a code, no longer uses text – this is not adopted by all
clearinghouses/payers so need Standard/Reinforcement of this transaction.
Some clearinghouses/payers not sending any acknowledgement. Need standard and enforcement.
Some will get the acknowledgement from the clearinghouse, but after it leaves there, the provider gets nothing from the next clearinghouse or payer.
Page 4 of 5 i. Would like acknowledgement from second or subsequent clearinghouse/payers
to flow back to the provider – possibly in reverse order of initial transaction ii. Would like a tracking system like UPS to identify who got the claim, where it is
sitting.
iii. There is a field in 277CA (acknowledgement number) that will let them know where the claim was received after it left the clearinghouse – need to educate providers where this is.
iv. Transparency critical because of resources. Need to know where claim is without opening multiple tickets.
v. If Provider calling Payer to find out where claim is, they payer receives a Reject Report from the Clearinghouse, which may give some information – this is not electronic at this time.
Provider doesn’t know that the clearinghouse dropped the bill to paper and the attachments were held up. When trying to solve, provider asked to print out and re-send attachments.
If attachments faxed, still are not linked to claim when sent to payer.
Provider needs to know (through acknowledgement) that the attachment is connected with the bill.
Some payers rejecting a claim through 277, and think it is a denial. Should be accepting the bill and sending an 835 as a denial, with a correct reason.
i. Payer education issue – need to use business scenarios to identify and standardize message of how each should be handled
No rules for Acknowledgements – should send one acknowledgement when claim is received, and another acknowledgement when attachment is received (if sent separately) and matched to bill.
Concern as to why this works for general health claims, but not Work Comp – when patient gives correct info at beginning of process – Registration. Work Comp payers are much smaller than general health claim payers, so may not be using most recent technology available
6. Bill processing, adjudication
Bills are reduced because Worker’s Comp has maximum fee allowed under specific CPT codes. Providers not able to find out why it was reduced.
i. Educate providers to use DLI website for this info. 7. Bill payment/remittance advice (EOB – 835)
EOB electronic version doesn’t match up with the claim – does not show patient ID, $ amount, etc.
i. Suggestion to bring payers into provider billing offices to see the issues first hand
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Need standard codes for 835 reasons for denial – clearinghouses use one set of codes, but payers have their own (larger set).
i. Educate payers of 835 reason codes
Bulk Check Process – random checks for multiple claims come sometime later than the EOB.
i. Bulk Checks should come with claim numbers that are associated with the check and come with paper EOBs of each so bill can be reconciled.
ii. Prefer no paper Bulk Checks – should send electronically so no manual reconciliation of bills.
iii. There are already 835 rules written for Overpayment Recovery and
Correction/Reversal – need industry wide education and enforcement of these rules. Possibly MN webinar with payers and 835 authors.
Virtual Payment (credit cards) – providers sent these credit cards by some payers, with no option to not use.
i. Work with Attorney General to identify/educate/fine
ii. Use Compact (quarterly articles) to educate on what can or can’t be done, Opt-out options, etc.
Payers choosing paper or credit cards, not EFT, with no options for providers. Should be electronic.
835 does not have check number on it that it goes with – often payer will send 835 before the check is created so the check number is not known.
i. Suggest hold 835 until the check is created, and then include the check number on the 835.
Some payers want provider bank account info so they can directly remove (debit) info if payer determines they have overpaid on an account.
i. Need rule about this – not appropriate. ii. Instead, need 835 clean edit process
Provider not notified electronically when clearinghouse/payer (1) has completed bill check and claim sent on to another clearinghouse/payer(2).
If claim doesn’t balance, provider should send Acknowledgement to clearinghouse, who sends on to payer that it is incorrect.
8. Acknowledgement (receipt of EOB – TA1, 999)
Often not get to this step because so many issues with Work Comp bill that it is easier to print off.
Payers will change mind during process of a bill to pay differently than when bill initially sent.
