Check out the latest report on Automatic healthcare remittance processing by Gordon Sellers - Director, Healthcare and Medical Banking Solutions at Systemware.

1. Automating Healthcare
Remittance Processing
TAWPI
Healthcare Payment Automation Summit
Chicago 9/14/09
Gordon Sellers
Director, Healthcare & Medical Banking Solutions
gordon.sellers@systemware.com

2. Providers Landscape
• 7000+ hospitals, clinics, surgery centers, etc.
• 450,000+ physicians in private practice
– Half in practices with more than 5 physicians
• Average 30% first pass denial rate per charge code
– Half due to eligibility issues
• Average administrative cost per submitted claim
– $10 to $12
• Average total administrative cost per secondary claim
– $8 to $10
• Administrative cost for appealed claims
– Can surpass $60
Source: Healthcare Financial Management Association

3. Why Medical Banking
• Currently banks provide:
– lockbox services such as deposit of payments
– imaging of checks
– imaging of paper EOB (some)
• What banks could provide:
– Data conversion
• of paper EOB’s into EDI 835 files for posting to Provider systems
– Balancing
• of claimed amount with paid amount minus any adjustments
– Process automation
• to reduce error rates and processing cost for Providers
– Visibility
• into the relationships between claims, payments and deposits
• Transactional discipline

4. Medical Banking

5. Extended HC Lockbox
• Medical Banking Application
– Capture & indexing of EDI 837 files
– Converts paper EOB’s into EDI 835 files
– Capture & indexing of EDI 835 files
– Automatic matching between EDI 835 files & EDI 837 files at the
claim and/or service line level
– Output of targeted file for upload into PMS at Provider
– Secondary / Tertiary claim preparation & submission
– Exception Management workflow queues
– Reporting
• Bank Administration Portal
– Set up & Administration of Providers
– Transaction Billing Report

6. Online Providers Experience
• Provider Portal (Bank Branding)
– Manage processing exceptions
• 837 /835 matching
• Secondary match to primary EOB image
• Secondary match to 835
– Download posting file
– Research denials for resubmission or
secondary
– Dashboards and report generation

13. Copyright © 2009 Systemware, Inc. 13

14. Medical Banking
• What banks SHOULD provide:
– Data conversion
• of paper EOB’s into EDI 835 files for posting to Provider systems
– Balancing
• of claimed amount with paid amount minus any adjustments
– Process automation
• to reduce error rates and processing cost for Providers
– Visibility
• into the relationships between claims, payments and deposits
– Transactional discipline
• banks have are good at this healthcare (providers) are not