April 18, 2019
Collection vendors, insurance payers, and even your state’s charity care organizations often do not adhere to the same file format standards as your payers. Insurance payers are bound to HIPAA ANSI standards mandated in 2003. From a hospital EMR provider perspective, these standardization requirements made it much easier to develop functionality to automate payment and adjustment posting. However, not all entities that provide payment and adjustment data to your organization are required to provide files in 835 formats. In these situations, most organizations must create custom interfaces or are forced to hand key payments and adjustments. Did you know – standard features and functionalities within your MEDITECH system can convert non-compliant payment files to 835s to post automatically?
Have you run into a scenario where you needed to take an adjustment on the back end, but the functionality of the EDI remit program could not handle it? Perhaps on a regular basis you receive an electronic file of accounts with payments and/or adjustments but are getting tired of having to manually key the information into a batch? By leveraging MEDITECH’s Non-Procedural Representation (NPR) Report Writer combined with an “835 Remit Delivery Service,” you can create and read-in your proprietary payment file formats to post adjustments and/or payments.
For example, a RevSpring client receives a monthly, comma -delimited text file containing the UCRN, claims total charges, and payment amounts. Using the NPR Report Writer, logic can be written linking the 835 file to the proprietary file. When this process is invoked, the NPR Report Writer reads in the file, calculates payments and adjustments, and then formats the data into a post-able 835 file. The file is then read into the Remit Delivery Service and creates an un-posted “collection” batch in MEDITECH. Cash posters can review the un-posted batch and then post the batch to finalize the adjudication of the accounts. The program also handles takebacks and reversals of prior payments.
In addition to using MEDITECH’s standard NPR Report Writer and Remit Delivery Service functionality to normalize propriatary data files, these features can also be used to handle outliers and unique payer requirements. A national payer, for example, might deem specific charges “experimental.” If and when these charges are billed to the payer, the subsequent payer remittance 835 file returns the charge amount as patient responsibility; however, you are not supposed to bill the patient for these charges. MEDITECH’s Electronic Data Interchange (EDI) program doesn’t have the capability to take adjustments by Current Procedural Terminology (CPT) code. To ensure the balance associated with the “experimental” charge is not billed to the patient in error, an NPR report can be created once the cash poster runs and after the 835 remit file is imported into MEDITECH. The report identifies accounts within the unposted batch and then creates a separate 835 file that handles these transactions appropriately. In this scenario, an adjustment is created to net down the experimental charges. For another scenario, the same logic can be used to add charges back into the patient balance. The key to isolating the accounts is targeting the line level data within the CAS segments and COB loops.
Whether the data resides within your Meditech EMR, a vendor’s proprietary file, or the payer’s 835 files, combining the features of NPR Report Writer and your EDI Delivery Service will offer the flexibility you need to handle even your most complex payer scenarios.
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