In today’s challenging healthcare environment where connectivity is key to optimal performance, the industry has experienced positive changes as providers and payers shift from paper-based claims to electronic healthcare transaction processing for workers compensation and automobile accident bills. The advent of electronic connectivity between providers and payers is not only generating rewards for providers, but it is also streamlining the nation’s entire healthcare system.

Sharing health information electronically enables providers to more effectively deliver higher quality, safer patient care. At the same time, electronic information exchange enhances provider practices through the electronic processing of medical bills and claims, known as EDI (electronic data interchange). This high level of connectivity is reducing administrative burdens and translating into greater efficiency and profitability.

Check out the key advantages that EDI delivers:

  • Faster reimbursement
  • No paper claims to stock and complete
  • Elimination of lost claims paperwork
  • Simplified record keeping
  • Reduced clerical time
  • Lower costs associated with processing and mailing paper claims

As this change continues to sweep across the industry, providers will find it helpful to understand how EDI works, be informed about best practices, and know what to look for when choosing an EDI clearinghouse partner to ensure seamless implementation.

Accurate Transmission of Medical Claims

Healthcare EDI is a structured opportunity to transmit data between computer systems, governed by industry standards that ensure accurate transmission of medical claims.

While other industries, such as banking and travel, have used EDI for decades, the healthcare industry has been slow to make the transition. What’s more, organizing and sending claims-related healthcare data between parties has been a complicated process, especially in the management of both patient medical records and health insurance reimbursement details.

Fortunately, greater efficiency in healthcare EDI implementation has been shown to help providers and payers save time and money.

Following Best Practices
Electronic claims can be generated in a practice management system and then transmitted directly to the payer electronically in accordance with the health plan’s submission requirements.

For a nominal fee, many providers choose to work with a clearinghouse, a private company that provides connectivity and serves as a “middleman” between physician practices, billing entities, payers, and other healthcare partners for transmission and translation of claims information into the specific format required by payers.

Providers submitting electronic claims directly to a payer may follow the ANSI (American National Standards Institute) standard formats currently in place. It is also critical to establish checks and balances to protect the privacy of information and ensure that the electronic claims are submitted in compliance with HIPAA requirements.

Providers also receive claim transmission status reports from a payer, clearinghouse, or other claims transmission vendor so that they have an electronic audit trail to assist in tracking the accepted or rejected status of all the electronic claims. When the physician practice is notified of a claim rejection electronically, it can quickly correct and resubmit the claim electronically.

Partnering with the Right Claims Clearinghouse

Before making the leap into paperless transactions, provider organizations and private practice physicians should consider partnering with a billing service or clearinghouse to submit claims and other EDI transactions. This is a critical first step to decreasing administrative costs and improving cash flow.

Industry-leading clearinghouses specialize in the electronic processing of healthcare claims for providers submitting workers’ compensation and automobile bills. It is anticipated that in most states, electronic billing will become mandatory for these sectors.

The EDI partner should also offer a platform that allows for the electronic submission of bills and supporting documents to payers resulting in faster processing, greater accuracy and increased cash flow for providers.

Important takeaway: EDI streamlines manual processes, helping healthcare providers enhance revenue and save time by ensuring appropriate reimbursement for their medical services and procedures.