Final-Capstone Matthew Mabalot 03 04 14

Streamlining Health Care Authorizations and Claims using a Secure Provider Portal: Best Practice Evidence and Pilot
Project
Matthew Mabalot HTM 692 Capstone National University San Diego, California 03/02/2014
Streamlining Health Care Authorizations and Claims using a Secure Provider Portal: Best Practice Evidence and Pilot Project 2
Table of Contents
Abstract.... 1. Project Definition........ a. Project Name......... b. Decision Makers....... c. Project Description...... d. Project Mission Statement........ e. Primary Stakeholders...... f. The Opportunity..... The Opportunity...... 2. 4 5 5 5 5 6 6 6 6
Literature Review 2.1 Literature Search Process........ 6 2.2 Methodology Section...... 7 2.3 Evidence Evaluation........ 8 2.4 Critique............. 10 2.5 Synthesis and Summary......... 15 2.6 Practice Guidelines........... 16 Project Scope........... 17 a. Prerequisites....... 18 b. Assumptions.......... 18 c. Project Constraints...... 20
3.
4. Project Schedule, Deliverables, and Budget..... 20 5. Project Goals and Objectives......... 22 5.1 Project Goals.......... 22 5.2 Project Objectives....... 22 6. 7. 8. 9. 10. 11. 12. Technical Requirements........23 Testing Plan........ 23 Training Plan......... 24 Deployment Plan..... 25 Post Deployment Services.....25 Solution Description...25 Justification for Recommended Solution...25
13. 14. 15.
Project Benefits...26 Lessons Learned..27 EDI/Provider Portal Future Phases.28
References.29 Appendices32 A1 A1.1 A1.2 A1.3 A1.4 Training Documents32 Batch File Claim Submission Training.....32 Batch File Authorization Submission.33 Online Claim Form Submission.35 Online Authorization Form Submission..37
Streamlining Health Care Authorizations and Claims using a Secure Provider Portal: Best Practice Evidence and Pilot Project 4 Abstract
Healthcare providers are slow to adopt new technologies such as using Electronic Data Interchanges (EDI) and secure provider portals in transmitting patient claim data and obtaining reimbursements despite the evidence showing that the technologies result in reduced costs, increases in data accuracy, and timely submissions and reimbursements. This Capstone Project reviews the literature and electronic websites to identify successful studies and strategies for implementing these new technologies, and makes evidence-based recommendations. A pilot project that capitalized on an improvement opportunity to implement these newer technologies in one office practice setting (Dr. Greens) by the Crayola Medical Group is described. The Crayola Medical Group is taking on the pilot project of implementing a secure provider portal for online claims and authorization submissions. The provider portal project will provide multiple transactions such as online claims and authorization submissions, leading the provider to recommend use of other transactions as well as encouraging other providers to follow their example. The provider portal will replace mail, fax, and courier services.
1. Project Definition- The project focuses on implementing a secure provider portal for a single provider office in a pilot project to test the effectiveness of methodologies. a. Project Name The full Project Name Implementing Claims and Authorizations Submission through a Secure Provider Portal. A secure provider portal is a web tool used as a central location to allow providers and payers to share data via secure network. A secure Provider Portal allows providers a browser-based view of all data sent and received from anywhere no matter where the data is stored. It includes the ability to streamline the communication between providers, health plans, and the managed care system (Bogoslaw, 2013). b. Decision Makers The decision maker for this pilot project is Dr. Green, owner of the providers office. c. Project Description The Crayola Medical Group is a managed care organization that focuses on the quality of healthcare services used by networked providers. The Crayola Medical Group specializes in the management of care for children by providing access to care within the network of providers. The Crayola Medical Group is taking on the pilot project implementing the use of the provider portal for Dr. Green who owns an existing Primary Care Physicians (PCP) office. Dr. Greens office is in the process of changing to a more automated office system. Dr. Green wants to embrace current technology to improve the timeliness of claim payments and authorization requests. Dr. Green, as the sole stakeholder, reached out to the Crayola Medical Group to execute a successful implementation and training campaign for his practice.
Streamlining Health Care Authorizations and Claims using a Secure Provider Portal: Best Practice Evidence and Pilot Project 6 d. Project Mission Statement
To Implement and train staff to use the secure provider portal for electronic transactions, including claim and authorization submissions while providing attentive, accommodating personnel. e. Primary Stakeholders The Crayola Medical Group is in the business of providing an online provider portal to providers to submit electronic data. It is funded by an experienced doctor who is a stakeholder in the first pilot project, Dr. Green. f. The Opportunity Opportunity Statement Dr. Green is an existing PCP office using traditional mail, fax, and courier services and is motivated to improve current office processes to promote standardization and efficiency using technology. Dr. Green has decided to pursue the installation of a secure provider portal in his office computer system. 2. Literature Review 2.1 Literature Search Process In conducting research for a secure provider portal within a managed care system, key search terms used included: Managed Care; Electronic Data Interchange (EDI); Provider Portal; Secure Provider Portal and Online Submissions. Specific categories, such as Benefits of a secure provider portal, and Benefits of Electronic Data Interchange were also used as search terms on Google search and the National University librarys smart search. Additionally, examples of organizations which have used EDI and/or a secure provider portal
were particularly wanted. The resulting journal articles and websites offered detailed information regarding the benefits of EDI and a secure provider portal. 2.2 Methodology Section A potential problem is obtaining participation from the managed care organizations and provider office, and ensuring each organization used EDI as the standard for all health care transactions. The studies completed illustrate what EDI has accomplished and what its potential is for the future. The evidence describes the cost savings and efficiencies of online electronic submission. The literature selected focused on the use of a secure provider portal and how it is useful. Health care is moving faster than it has ever moved before. The opportunity now is to use this evidence and put it into practice using the new technology. The number of electronic claims processed has increased in larger hospital settings and must be used in the smaller networks as well. The literature search provides evidence that health care costs will decrease and productivity will increase with the use of the EDI standards. The solution to the problem is to influence organizations to adopt technologies such as a secure provider portal. The literature selected focused on medical groups that have implemented EDI transactions into their current processes. The literature also provided information about the importance of a provider portal and how others benefited from using the portal to submit electronic data. The research found examples of successful implementations. The research also found that healthcare providers are slow to adopt innovations that will improve claims
processing, but implementation of EDI with a secure provider portal is an important way to improve data transmission while at the same time reducing costs. 2.3 Evidence Evaluation 1=meta-analysis of multiple research 2=single research paper 3=quality studies or other non-research evaluations in the literature 4=expert opinion 5=Vendor reports 6=Other Evidence Evaluation Study Objective Evidence Score
Reference Bogoslaw, D. (2013). Provider Interactions Need Administrative Streamlining: Design a Portal that Satisfies Provider Needs. Managed Healthcare Executive, 50-52.
Study Results
Exploring the Costs reduced by reducing wasted money needs of a on administrative tasks. More time and provider portal money is spent on patients 3
Girton, T. A., & Haupert, C. S. (1996). EDI Helps Group Practices Manage Costs
Studies on cost Reduced costs in managed care. Number savings with of errors reduced. Improved productivity the use of EDI
Hansen, B. (1996). Exploring the Benefits of FullService EDI Networks.
Understanding the benefits of using EDI Networks.
Proven problem that paperwork and performing administrative tasks manually contribute to the rising cost of health care. Giving providers access to EDI systems Proven lack of standardization when reporting client information. EDI and a Provider portal proved to be methods to improve the way we report healthcare services
Loshin-Turso, F. (2012). Making EDI Standardization a Priority in 2012: 'Stone Age' Reporting Methods Sap Providers and Drain Service Resources. Behavioral Healthcare, 41-43. Schulaka, C. (2012). What Can Web Portals Do for Me?. Journal Of Financial Planning, 25(3), 3335. McMullen, T., Martin, C., & Bilbrey, D. J. Survey Reveals EDI Claims Volume.
Evidence on the benefits and importance of standardized data and provider portals
To prove how web portals are used and the importance
Web portals were proven to be very useful and cost effective 1
To view the volume of claims processed efficiently with the use of EDI. Survey reviewed volume of claims processed electronically compared to manual.
400 million claims processed from more than 100,000 providers representing more than half a trillion dollars. estimated that 35% to 40% of physicians still rely on paper claims submissions
Moynihan, James. First steps in managed care EDI.
To view the benefits of implementing EDI transactions and the first steps to take To display that Electronic Transactions alone are not suffice because of various payers and providers
EDI transactions are beneficial when implemented in steps

2
Goedert, J. (2003). Electronic transactions: Standards aren't common
EDI standards alone are not enough to implement
Goldsmith, J. payerprovider connectivity: progress elusive but possible.
To show the The importance of connecting providers importance of to a provider portal to submit electronic connecting transactions both payer and provider through a web portal
2.4 Critique. The literature describes the benefits and effectiveness of implementing a secure provider portal within a provider network. It is important to learn from previous implementations and case studies to compare where healthcare was in 1996 and where it is today. The pilot project was chosen on the basis of the information found in the literature. After almost twenty years of literature providing evidence of efficiency with the use of EDI, many healthcare providers are still slow to adopt technology and continue to submit paper checks, claims, authorizations, and referrals.
The journal article, Exploring the Benefits of Full-Service EDI Networks (Hansen, 1996) supported the benefits of EDI through information gained by conducting surveys and research on how EDI lowered costs and facilitated processes. The survey results from the parallel testing showed a significant increase in improvements in administrative processes and cost savings. Hansens (1996) research promotes the use of EDI in a healthcare organization, arguing that a full-service network allow providers to connect to payers who can accept EDI transactions and improve processes within the network. Moynihan (1996) discussed implementing EDI transactions years ago and has proved that the implementation resulted in cost savings. The best practice used in 1996 is still useful in todays healthcare . Moynihan (1996) originally focused on implementing one transaction at a time, but the technology soon advanced into multiple transaction processing. Moynihans (1996) research achieved success when implementing the authorization transaction through an online portal. After the authorization submission was implemented through the portal, eligibility inquiries were then followed. Both Moynihan and Hansen proved that operating costs decreased after the implementation of each transaction from both authorizations and claims. Hansen was part of the Health Information Networks and Technology (HINT) Project. The HINT Project, conducted by Thomas Edison State College and the New Jersey Institute of Technology, involved surveying various healthcare providers in the New Jersey region (Hansen, 1996). Additionally, the survey results indicated that those participating in EDI noted a lower average rejection rate for both initial claims and follow-up claims than paper-based claims; and a shorter turnaround time on accounts receivable than paper-based claims (Hansen, 1996 p.
64). Hansens results are important to help providers understand the effectiveness of EDI. The survey results supporting the financial argument projected hospitals that submit 3,000 paperbased claims per month could save about $24,000 a year if they transmitted the claims electronically (Hansen, 1996 p.64). According to Fran Loshin-Turso, president of the Software and Technology Vendors Association (SATVA), president and CEO of Defran Systems, and author of Making EDI Standardization a Priority in 2012: Stone Age Reporting Meth ods SAP Providers and Drain Service Resource, there is a lack of standardization when reporting tracking information (Loshin-Turso, 2012). The standardization of electronic submission is difficult to accomplish when the payer and provider network do not work together. Loshin-Turso argues that many providers operate in a relative stone age (Loshin-Turso, 2012 p.41), because their processes report client information using paper files and systems which do not support EDI. Additionally, Loshin-Turso suggests that administrative and data entry costs accompany the current process and are considered a pure waste (Loshin-Turso, 2012 p.41). The use of a Provider Portal is a channel for all providers to employ when communicating; allowing a common language to exist between the provider and the managed care system. Loshin-Turso (2012) used qualitative methods to explore the use of a common language. The points made in the article were that providers were not up to date with todays technologies and emphasized the importance of making the use of EDI a priority. EDI transactions, such as claims processing, eligibility verification, and remittance advice, are efficient and cost effective. Giron and Haupert (1996) discussed ways in which EDI
will reduce administrative costs, reduce the number of errors on claims, and increase productivity. Girton and Hauper described how EDI transactions benefit managed care systems by resulting in a decline in administrative costs, such as: shipping costs; mailing costs; printing costs; and clerical salaries. Additionally, the use of EDI will ultimately reduce manual tasks and data entry errors, and increase productivity. Lastly, EDI transactions will result in an increase in timely payments and a decrease in the amount of rejected claims. While there are many possibilities which EDI offers, the process must be implemented in partnership with a secure provider portal. Although the article referred to a practice done years ago, it clearly explained the types of transactions that were implemented to improve processes. Girton and Hauper emphasize the benefits achieved from specific transactions. Girton and Hauper (1996) studies showed evidence of EDI effectiveness but did not emphasize how the transactions would be delivered. The pilot project would emphasize both the use of the EDI transactions as well as delivering information through a secure provider portal. Goedert (2003) has emphasized how using EDI transactions and web portals to submit claims and eligibility requests are important. But realistically, not all providers will embrace the use of these technologies unless it has been proven effective and affordable. A lesson learned from Goederts was preparing for the resistance of providers who are not ready to change current processes. Providers will embrace the technology only when persuaded of the benefits, and this may occur when they read about a successful implementation of a secure provider portal.
A current and fully operational provider portal includes the web-based system, EZ-NET, which was designed by MZI Healthcare, LLC (2013). The organization vendor, MZI Healthcare has been in operation for over 25 years. Their philosophy is to develop and provide sophisticated software solutions that are flexible, reliable, cost effective and help simplify a complex industry (MZI Healthcare, LLC, 2013 n.d.). MZI Healthcares web based portal, EZ-NET offers a multitude of benefits to healthcare organizations, allowing information to be easily accessible without compromising security (MZI Healthcare, LLC, 2013 n.d.). The product that MZI offers is a one stop shop for EDI transactions and provider portal. In Bogoslaws (2013) quality studies, he noted that a portal will not only provide ease in the exchange of electronic data, but will allow cost savings. According to a 2012 Institute of Medicine report, about 30% of health spending is attributed to waste and some of that waste came from excessive administrative tasks (Bogoslaw, 2013 p.50). This journal article provided information on how much time is wasted doing paperwork. The provider portal was clearly defined by Bogoslaw (2013) as well as the need for such a tool to transmit electronic data. The use of EDI with a secure provider portal will support the exchange of electronic data, in real-time, and without an extended delay in response. Real-time transactions, such as eligibility determination and authorizations, are a critical facet of the administrative tasks performed in a managed care system because interactions between payer portals and providers often start with real-time verification of a members eligibility and benefits (Bogoslaw, 2013 p. 51). Additionally, real-time transactions are important because claims adjudication tells a provider within seconds how much the payer will cover and what the
patient owes, allowing collection from the patient at the point of care (Bogoslaw, 2013 p.51). Lastly, a secure Provider Portal is helpful in that it is needed to assist providers in making referrals and authorizations with the use of pre-populating fields, which ultimately saves data entry time and prevents data entry errors (Bogoslaw, 2013). Schulakas (2012) analysis of multiple research studies described best practices in the article what can web portals can do for me by initiating providers to want to implement a provider portal to make electronic transactions more efficient. To influence providers to get on board with new technology, it must be done in increments. Incrementally introducing technology is a great method to motivate providers to use the provider portal. It is challenging to try to implement multiple transactions or technology to clients because it can discourage providers from participating. 2.5 Synthesis and Summary The literature review supports the claim that healthcare operational costs could be decreased, and productivity increased with the use of the EDI standards and a secure provider portal. The research concluded that a managed care system will benefit from the use of secure provider portals. Claims, eligibility, and authorization transactions are a critical aspect of the managed care system because each transaction facilitates the way providers send and receive information within their own network of providers. The literature proves the effectiveness of the methodology of submitting electronic inquiries through a provider portal. The challenges are influencing providers to embrace the technology before it becomes a CMS mandate to submit all healthcare transactions electronically.
The literature found discussed both EDI utilization and a secure provider portal and all the literature were consistent with the findings as far as cost savings and effectiveness. There are several ways to submit electronic claims but the best practice would be to use a secure provider portal offered by the payer or managed care organization. To initiate the use of a secure provider portal, it is important to find a provider office that is willing to embrace the new technology and benefit from the results first hand. 2.6 Practice Guidelines To obtain electronic healthcare information in a quick, efficient, and effective manner, it is recommended that managed care systems use a secure provider portal for electronic submissions. 1. The solution involves encouraging the managed care system to participate in the opportunity to improve the interoperability of systems for exchanging data. Once the managed care system is prepared to move forward with the decision to use online submission through a secure provider portal, implementing the process then follows. 2. Allow providers to adopt technology seamlessly by implementing one transaction at a time. A demand that a provider implements multiple technological projects at the same time can be intimidating to the people in a provider office. It is best to start off with one transaction and support the project to a successful implementation. The one successful implementation can encourage the staff to try another, and eventually achieve multiple successful implementations. It is important to provide the first small success as the starting point for future projects
3. Implementing technology and new processes, such as an online submission of electronic data through a secure provider portal, integration must be seamless to the providers. Processes must be in place prior to implementation, and resources must be available during the transition. 4. Make the change as easy as possible for providers by helping them understand exactly what the change is and how they will benefit in the end. First step is to identify the best way to transition current processes into the new processes for all entities. The success of the implementation is dependent on the buy-in of the organization and users who will be using the portal. It is highly recommended that the managed care organization contact the providers within the network early to help them understand the benefits of using the provider portal and adopting the EDI transactions. 5. Although the provider portal will have many capabilities, it is important not to implement too many at one time. The pilot project will be a gateway for providers to start embracing new technology.
3. Project Scope The following is an outline of the scope of the project, detailing the tasks needed to implement the provider portal project for Claims and Authorization submissions. In Scope 1. Information Systems consulting 2. Create and maintain project plan
3. Facilitate weekly project team status report 4. Training manuals will be provided to Dr. Green and his staff after training and testing is complete. 5. Testing online submissions 6. Implementation Out of Scope 1. Support and provide claims provider offices with information and easy to manage provider portal after implementation 2. Testing other transactions a. Prerequisites The prerequisites for a successful project are the engagement of the stakeholders, availability of the IS consultant, and provider office staff, availability of an Internet Service Provider, and the permissions to upload and download data from the portal. The responsibility for this has been assigned to the Crayola Medical Group. b. Assumptions The working assumptions brainstormed by the core team (which included the providers representative) are the following: 1. The Crayola Medical Group will document and translate the provider needs into a FAQ document to meet the needs. 2. The Crayola Medical Group will provide training and access to the provider portal
3. Since the technologies are changing quickly, testing will be provided weekly to add the best value to the transition. 4. Test files will be provided by the providers office to submit claims and authorizations online through the provider portal. Crayola Medical Group will validate testing with the provider portal before project is complete to allow for timely transition to production. 5. Dr. Green already submits some claims via clearinghouse and will transition to the provider portal. Once the claim submission has been tested and moved into production, authorization submissions will be tested, and then moved into production. 6. The secure provider portal is a benefit to Dr. Green and will increase efficiency and reduce delays and costs. 7. Crayola Medical Groups provider portal is the best solution to eliminate errors and rekeying of claims for Dr. Green. 8. Dr. Green will pay Crayola Medical Group for their assistance with the transition and other services. The Crayola Medical Group will assume all costs as part of the long term contract. 9. Upon approval, the project will take approximately 7 weeks with a go live date into production on week 8. 10. There is not a set budget. However, Dr. Green will not spend more than $1,000 for this project. Any costs over $1,000 will be assumed by Crayola Medical Group.
c. Project Constraints For most projects, the most frequent constraints include time, scope, and cost. Some projects extend the model to include quality, risk, and other factors that limit options when managing a project or task deliverables. There are five limitations associated with pursuing this project: 1. The project team has limited resources and staff. All communication is via email and GoTo meeting. Documents are shared on share point. 2. There is a budget of $1,000. 3. The provider portal must be accessible from any personal computer 4. Technology changes at a rapid rate. Adaptations to the project may need to be made in order to achieve the objective. 5. The project must be completed by January 19, 2015
4. Project Schedule, Deliverables, and Budget The pilot project is relatively small, and represents the first and second phase in a sequence of phases to follow, which will complete the implementation for this pilot project. Work Breakdown Structure (WBS) WBS 1 1.1 1.3 Name Initiating Form team to conduct pilot Prepare, review, and approve Start Date 1/1/2015 1/1/2015 1/1/2015 Finish Date 1/1/2015 1/1/2015 1/1/2015
project charter 2 2.1 2.2 Planning Hold project kick-off meeting Prepare scope statement [subset of tasks and products for pilot] Prepare work breakdown structure Prepare schedule Identify risks, constraints SWOT Risk Matrix Prepare, review, and present Project Definition Report Obtain approval and commitment to be involved by Crayola Medical Group Stakeholders Executing 3.1 Testing online submission 3.2 Training Implement claim and 3.3 authorization submission 3.4 Closing Table1 Project Timeline 1/10/2015 1/10/2015 1/10/2015 1/24/2015 1/10/2015 1/10/2015
2.2.1
1/10/2015
1/10/2015
2.3 2.4 2.5 2.5.1 2.5.2
1/16/2015 1/19/2015 1/17/2015 1/17/2015 1/17/2015
1/16/2015 1/19/2015 01/17/2015 1/19/2015 1/19/2015
2.6
1/15/2015
1/24/2015
2.7 3
1/24/2015 1/29/2015 1/29/2015 1/29/2015
1/24/2015 1/29/2015 3/19/2015 3/19/2015
1/29/2015 3/19/2015
3/19/2015 3/19/2015
The major deliverables for this pilot project are: Team Charter 1. Project Definition Plan
2. Testing Plan 3. Implementation Plan for successful data transmission of patient claims and authorizations.
4. Budget Plan 5. The provider estimated budget for the project is shown in the following table: Service Site Review (optional) PC hardware (Optional) Testing Technical Support Table2. Budget Estimates Budget Estimate $500 on time fee $500 one-time fee Free Free
5. Project Goals and Objectives 5.1 Goals The project goals are to implement online claim and authorization submission through a secure provider portal for providers to use to send data to the Crayola Medical Group. The transactions to be implemented in the pilot project are electronic submissions, and responses via online form and file upload services into payer system to improve timeliness of submissions. The provider will be able to access the portal and have a user friendly interface to use the services. The implementation will benefit both the provider and managed care organization. 5.2 Objective The objective is to provide online capability to providers that will result in the providers ability to electronically submit authorizations and referrals for patients to see a specialist. Another objective is to improve reporting on claim tracking and inventory. Providers
will have the ability to submit online claims or file uploads through the provider portal. Training and implementation will be a smooth transition for all providers interested in improving their practice. The project will be used as an example to encourage other providers to follow. The Crayola Medical Group will increase the volume of providers using the online provider portal. 6. Technical Requirements The Crayola Medical Group evaluated the technologies required to access the provider portal before making a decision. The requirements include Internet Explorer 8 and up, Internet Provider, and Personal Computer minimum of 2 GB of RAM. I5 CPU 2.6 GHz. The technical requirements are referenced in Table 3. Name Internet Explorer 8.0 PC Windows Type Software Hardware Operating System Version 8.0 I5 2 GB RAM XP and up Purpose Scripting Language Windows Based Operating System
Table3. Technical Requirements
7. Testing Plan
The plan produces a baseline of user performance, validates user functionality and identifies issues to improve the efficiency and end-user satisfaction. The usability test objectives are: To determine usability problem areas within the user interface and content areas. Potential sources of error may include:
Navigation errors failure to locate functions, excessive keystrokes to complete a function, failure to follow recommended screen flow.
Presentation errors failure to information in screens, selection errors.
To exercise the provider portal under controlled test conditions with representative users. Test files will be uploaded and validated
The user will test all functions and check off as completed and functional Testing Checklist
Function Web Access Batch Online Claim Submission Batch Online Authorization Submission Online Form Claim Submission Online Form Authorization Submission Table5. Testing Checklist
8. Training Plan
PASS x x x x x
FAIL
For this handbook, an objective is to provide a step by step process on how to navigate through the provider portal and update services with customized pictures or keywords. Two hour Training sessions will be held remotely on users desktop to include the following nine Training Topics: 1. Logging in and creating passwords 2. Navigating through provider portal 3. Generating reports 4. Uploading/Downloading 5. Inventory Reports 6. Updating service requests 7. Questions
Streamlining Health Care Authorizations and Claims using a Secure Provider Portal: Best Practice Evidence and Pilot Project 25 9. Deployment Plan
The Crayola Medical Group will provide quality assurance check with the communication between the provider portal and the provider office. After testing and training is complete, all functions will be tested by the provider and validated by Crayola Medical Group. Once all has been validated, production files will be requested and moved into production. A training manual will be given to the provider and billing department during testing and training.
10. Post-Deployment Services
The Crayola Medical Group will provide the following after implementation 1. Technical Support 2. Customer Service 3. Monthly Conference Calls 4. Monthly summary report claims and authorization inventory
11. Solution Description.
The Crayola Medical Group offered a solution to a small providers office owned by Dr. Green who provides a high volume of health care services but lack the technology to keep up with the timeliness of claim and authorization submission. The Crayola Medical Group encouraged the provider to use the provider portal that is user friendly and ready to be used. Submitting EDI transactions and online forms provides reduced costs, tracking inventory, accurate data, and timely submissions. Through the efforts of both the Crayola Medical Group and Dr. Green, the project will quantify results to move on to the next phases of EDI transactions.
12. Justification for recommended solution
The recommended solution is training and implementing providers on how to use the provider portal. The first phase is claim submissions and the second phase is online authorization requests.
Justifications: Providers Use of the provider portal gives the provider an advantage to reduce administrative costs involved in faxing and mailing of claims and authorizations. Support Providers will be able to track claims and authorizations through our provider portal. Costs Investing in training and implementation saves the managed care organization and provider offices money compared to traditional fax, mail, and courier services. The costs for using the provider portal will pay for itself from the high volume claims and authorization inquiries submitted in a timely manner. It will also reduce the billing cycle which will add to the profitability of the provider organization. Time Organizations save time and effort in dealing with interoperability. Time is also saved in a one stop shop of healthcare transactions such as ANSI 837 claims and ANSI 278 authorizations.
13. Project Benefits
The project benefits are the abilities to enhance services and techniques in the future by completing the pilot project to the end. Throughout the project, the Crayola Medical Group will benefit by learning and understanding more about what could be improved and what functions worked the best. The benefits for our provider through the pilot project are a high volume claim submissions and authorization requests submitted without delays. The pilot project benefits from the time and money saved by visiting a single provider portal to manage all electronic transmissions. Once online claims and authorizations submission have been achieved, future transactions can be adopted such as eligibility inquiries, provider credentialing, ERAs, and EFT.
Streamlining Health Care Authorizations and Claims using a Secure Provider Portal: Best Practice Evidence and Pilot Project 27 14. Lessons Learned
Maintenance plan: The provider portal is fully capable of most health care transactions and is a work in progress as far as encouraging and training providers to use all aspects of the portal. Maintenance in this case is considered a stepping stone for the company to grow and expand. As more information is presented, the targeted audience will be hospitals, specialists, and other primary care offices. As new HIPAA requirements arise, functionalities will be improved upon, and, more functionality will be added to the portal. Training will continue to improve as more providers are motivated to use the portal. Technical improvement: Training sites can be improved through web training sessions. EDI transactions can be simplified through the use of tab delimited files or excel files. Continuing to provide training and testing with providers will make transitioning into other transactions seamless. Once claims and authorization submissions are fully electronic, future online submissions can be implemented and used as an evidenced based practice. Small Primary Care Offices and hospitals seeking a cost effective way to manage their administrative health care services can move forward with no resistance. Another lesson learned is ensure that all persons involved in the project use the same file format when testing the provider portal. Due to various file formats and systems, multiple formats will have to be considered for those offices not capable of generating EDI transactions. In addition, eligibility transactions should be included in phase 1 considering eligibility is an important factor in paying claims and authorizing services. The testing and training provided excellent feedback on the future implementations for other health care organizations. Future enhancements to the provider portal would be contingent on the use of the provider portal by a larger volume of providers. Future implementations can be improved by
providing an online training program that allows providers to test and complete training with minimum human intervention.
15. EDI/Provider Portal Future Phases
Phase Phase 1 Phase 2
Transaction Description Claims Authorization Request Claims Status/Acknowledgement Eligibility Inquiry/Response Electronic Remittance Advice Payment Orders
X12 ANSI 837P/837I ANSI 278
Projected Start Dates 01/01/2015 01/01/2015 01/01/2015
Phase 3 Phase 4 Phase 4 Phase 6
ANSI 276/277 ANSI 270/271 ANSI 835 ANSI 820 03/01/2015 03/01/2015 04/01/2015
Table8. EDI/Provider Portal Future Phases
Streamlining Health Care Authorizations and Claims using a Secure Provider Portal: Best Practice Evidence and Pilot Project 29 References
ASC X12. (2013). About ASC X12. Retrieved from ASC X12 Accredited Standards Committee: http://x12.org/x12org/about/index.cfm Bogoslaw, D. (2013). Provider Interactions Need Administrative Streamlining: Design a Portal that Satisfies Provider Needs. Managed Healthcare Executive, 50-52. CMS. (2013, 12 03). Center for Medicare and Medicaid Services. Retrieved 2013, from Center for Medicare and Medicaid Services: http://www.cms.gov/Regulations-and-Guidance/HIPAAAdministrative-Simplification/Affordable-Care-Act/OperatingRulesforHIPAATransactions.html Freedman, I. (2007). What Does "Interoperability" Really Mean? Health Management Technology, 28(10), 50-51. Girton, T. A., & Haupert, C. S. (1996, June). EDI Helps Group Practices Manage Costs. Health care Financial Management, 50. Retrieved October 12, 2013, from http://web.ebscohost.com.ezproxy.nu.edu/ehost/detail?sid=e53b349b-89b9-43dd-893679dad948c7c3%40sessionmgr14&vid=1&hid=10&bdata=JnNpdGU9ZWhvc3QtbGl2ZQ%3d%3d#d b=buh&AN=9606250899 Goedert, J. (2003). Electronic transactions: Standards aren't common. Health Data Management, 11(11), 36-40, 42. Retrieved from http://ezproxy.nu.edu/login?url=http://search.proquest.com/docview/219578062?accountid=2 5320 Goldsmith, J. (2008, February). Payer-provider connectivity: progress elusive but possible. hfm (Healthcare Financial Management). pp. 62-66.
Hansen, B. (1996, January). Exploring the Benefits of Full-Service EDI Networks. Healthcare Financial Management, 50, 64-66. Retrieved October 10, 2013, from http://web.ebscohost.com.ezproxy.nu.edu/ehost/detail?sid=a49d2bc1-de44-4f01-b344e0c0ced4aa80%40sessionmgr4&vid=1&hid=10&bdata=JnNpdGU9ZWhvc3QtbGl2ZQ%3d%3d#db =buh&AN=9601294115 Harris Healthcare Solutions. (2013). Provider Portal. Retrieved from Harris Healthcare Solutions: http://healthcare.harris.com/solutions/products/provider-portal.aspx Kolkman, L., & Brown, B. (2011). The Health Information Exchange Formation Guide. Chicago: Healthcare Information and Management Systems Society. Loshin-Turso, F. (2012). Making EDI Standardization a Priority in 2012: 'Stone Age' Reporting Methods Sap Providers and Drain Service Resources. Behavioral Healthcare, 41-43. McMullen, T., Martin, C., & Bilbrey, D. J. (2009, April 01). Survey Reveals EDI Claims Volume. Retrieved from managedhealthcareexecutive.modernmedicine.com: http://managedhealthcareexecutive.modernmedicine.com/managed-healthcareexecutive/news/survey-reveals-edi-claims-volume Moynihan, James. (1996, March).First steps in managed care EDI. Health care Financial Management. MZI Healthcare, LLC. (2013). EZ-NET. Retrieved from MZI Healthcare, Optimizing the Health of Your Business: http://www.mzihc.com/products/ez-net/ MZI Healthcare, LLC. (2013). Our Company. Retrieved from MZI Healthcare, Optimizing the Health of Your Business: http://www.mzihc.com/our-company/
PR, N. (2013, November 25). Workgroup for Electronic Data Interchange to Provide New Roadmap for Health IT Industry at NPC Newsmakers News Conference. PR Newswire US. Schulaka, C. (2012). What Can Web Portals Do for Me? Journal of Financial Planning, 25(3), 33-35. Simonet, D. (2007). Managed Care in the USA: origins, HMO strategies and the marketing of health services. Journal of Public Affairs (14723891), 7(4), 357-371. doi:10.1002/pa.274
Streamlining Health Care Authorizations and Claims using a Secure Provider Portal: Best Practice Evidence and Pilot Project 32 Appendix A1. Training Documents
Below are training documents that will be given to the provider for training purposes. During the implementation providers will test both online batch submissions as well as online form submissions. The training documents include both Claims and Authorization Submissions.
A1.1 Batch file Claim Submission Training
File formats provider portal will accept ANSI 837P/837I files, Electronic Proprietary Format (EPF), or Tab Delimited files. Enter username and password
File Extensions accepted are TXT, DAT, ZIP, CSV
1. Click on the Tab Ez-EDI, then click on Submitter Services, Professional Claims and select file format.
2. Select File to upload
3. Check the Box [Process], claims will be validated. Once validation is complete, click [Post]. Claims will be posted to the Payer Claim System for Processing.
A1.2 Batch File Authorization Submission
File formats provider portal will accept ANSI 278 files, Electronic Proprietary Format (EPF), or Tab Delimited files. Enter username and password
1. Click on the Tab Ez-EDI, then click on Submitter Services, Auth/Referrals and select file format.
File Extensions accepted are TXT, DAT, ZIP, CSV 2. Select File to upload
3. Check the Box [Process], claims will be validated. Once validation is complete, click [Post]. Claims will be posted to the Payer Claim System for Processing.
A1.3 Online Claim Form Submission
Enter username and password
1. Click on the Tab EZ/EDI>> Claim Forms/ and select claim form desired
2. Enter Information in each required field (BOLD FIELDS ARE REQUIRED).
3. after completing all required fields, Click [Submit Request]. Claims have been submitted to the payer system.
Streamlining Health Care Authorizations and Claims using a Secure Provider Portal: Best Practice Evidence and Pilot Project 37 A1.4 Online Authorization Form Submission
Enter username and password
1. Click on the Tab Main Menu >>Auth/Referrals >> Auth Submission 2. Enter Information in each required field (BOLD FIELDS ARE REQUIRED). 3. after entering data in all required fields, Click [Submit Request]. Claims have been submitted to the payer system.

Final-Capstone Matthew Mabalot 03 04 14

Hochgeladen von

Dokumentinformationen

Originaltitel

Copyright

Verfügbare Formate

Dieses Dokument teilen

Dokument teilen oder einbetten

Freigabeoptionen

Stufen Sie dieses Dokument als nützlich ein?

Sind diese Inhalte unangemessen?

Copyright:

Verfügbare Formate

Final-Capstone Matthew Mabalot 03 04 14

Hochgeladen von

Copyright:

Verfügbare Formate

Streamlining Health Care Authorizations and Claims using a Secure Provider Portal: Best Practice Evidence and Pilot

13. 14. 15.

Project Benefits...26 Lessons Learned..27 EDI/Provider Portal Future Phases.28

Hansen, B. (1996). Exploring the Benefits of FullService EDI Networks.

Understanding the benefits of using EDI Networks.

To prove how web portals are used and the importance

Web portals were proven to be very useful and cost effective 1

Moynihan, James. First steps in managed care EDI.

EDI transactions are beneficial when implemented in steps

Goedert, J. (2003). Electronic transactions: Standards aren't common

EDI standards alone are not enough to implement

Goldsmith, J. payerprovider connectivity: progress elusive but possible.

2.3 2.4 2.5 2.5.1 2.5.2

1/16/2015 1/19/2015 1/17/2015 1/17/2015 1/17/2015

1/16/2015 1/19/2015 01/17/2015 1/19/2015 1/19/2015

1/24/2015 1/29/2015 1/29/2015 1/29/2015

1/24/2015 1/29/2015 3/19/2015 3/19/2015

Table3. Technical Requirements

Presentation errors failure to information in screens, selection errors.

Phase Phase 1 Phase 2

X12 ANSI 837P/837I ANSI 278

Projected Start Dates 01/01/2015 01/01/2015 01/01/2015

Phase 3 Phase 4 Phase 4 Phase 6

Table8. EDI/Provider Portal Future Phases

File Extensions accepted are TXT, DAT, ZIP, CSV

2. Select File to upload

A1.2 Batch File Authorization Submission

A1.3 Online Claim Form Submission

Enter username and password

2. Enter Information in each required field (BOLD FIELDS ARE REQUIRED).

Enter username and password

Das könnte Ihnen auch gefallen