infocus - availity · 2 availity infocus | dec/jan 2011-12 time is ticking away before the hipaa...
TRANSCRIPT
Dec | JAN 2011-12
inFocusNewsletter for users of the Availity® Health Information Network
A “Real” Gift for Your CompanyFewer Headaches, More Payments
Log in • contact us • avaiLity.com
NEW!Availity inFocus (formerly Availity eFocus) has a brand new look and content. Tell us what you think— email us at [email protected]
News Events Training
Reimbursement blues have you looking for tools to help you collect every possible dollar? You’re not alone.
contents
A “Real” Gift for Your Company Fewer headaches, more payments
Reimbursement blues have you looking for
tools to help you collect every possible dollar?
You’re not alone.
5010 Update Center Your source for HIPAA 5010 news, tips and training
Feeling a little Y2Kish? Don’t despair. Here’s
what you need to know about the deadline
and your Availity transactions.
Spotlight On CareProfile® for winter travelers
Sick travelers with no health records?
With CareProfile, it’s no problem.
Case Files
What's New?
Events
Training
Crosswo rd
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CareCost Estimator and Remit Reader are service marks (SM) of Availity, LLC.
CareCollect, CareProfile, CarePrescribe, and CareRead, are registered trademarks (®) of Availity, LLC.
CareCalc is a registered trademark of Blue Cross and Blue Shield of Florida, Inc.
ContactFor newsletter suggestions: [email protected] customer support: [email protected] P.O. Box 550857 Jacksonville, FL 32255-0857 1.800.AVAILITY (282.4548)
5010 Quick Tips A one-page reference for important 5010 changes
Availity inFocus, December/January 2011-12
www.availity.com 1
A “Real” Gift for Your CompanyFewer headaches, more payments
The pressures on health care
providers these days are
seemingly endless, from adoption
of new technology, to practice
consolidation, to changes in the
health care delivery process. But
you can capitalize on these changes
through effective revenue cycle
management, and give yourself and
your practice the gift of “one less
thing to worry about”—getting paid.
If you’re like most providers,
reimbursement pressures are
forcing your practice to focus on
the most efficient revenue cycle
management (RCM) process to
ensure that every possible dollar
is collected. That’s why more
providers are looking for revenue
cycle management solutions. With
average administration expenses
exceeding $85,000 per physician,
according to a 2009 study1, many
physicians are looking to fully
automate their processes and drive
economies across their business.
The study found that more than 50
percent of those administrative costs
were directly tied to interactions with
health plans, including:
• Follow-upandpayment
reconciliation
• Receivingandpostingpayments
• Creatingandfilingclaims
• Reimbursement
• Serviceauthorizations
• Clinicalcoding
• Databasemanagement,and
• Payerrelations
Automated revenue cycle
management gives you a lot of that
time back, allowing you and your
practice staff to focus on other
activities, like patient care.
Take an anesthesia practice in
western North Carolina, the subject
of a recent case study conducted
by RealMed, an Availity company.
This30-physicianpracticefaceda
growing accounts receivable file
and a payment collection process
that was too slow, so they went in
search of a technology solution that
would reduce time to payment, claim
rejectionsandback-enddenials.What
theyfoundimpressedthem.Fora
copy of this case study, click here.
The practice had historically
followed up on unpaid claims at
the120-dayagingmark,
story continued on page 8
A North Carolina anesthesia practice saw a 75% reduction in days in accounts receivable, from 28 days to less than seven days.
1 J.A. Sakowski et al. “Peering into the Black Box: Billing and Insurance Activities in a Medical Group,” Health Affairs Web Exclusive, May 14, 2009, w544-w554.
Learn more about RealMed and revenue cycle management at realmed.com, or call 1.877.REALMED
2 Availity inFocus | Dec/Jan 2011-12
Time is ticking away before the HIPAA
5010 compliance deadline of Jan. 1,
2012. Availity will be fully compliant with
the deadline, and will accommodate
everyone else who is as well.
Although CMS recently granted a
grace period for enforcement of the
deadline, Availity’s best guidance is
that you should continue to prepare
for the transition now, to avoid
extended disruption later.
Following are answers to a few
questions we’re already hearing.
More FAQs and general 5010
information are available at
www.availity.com/5010/.
Will Availity be down for any period
of time near January 1, 2012?
See the timeline graphic below for
details on Availity's 5010 migration.
FAQ continued on page 3
5010 Update CenterYour source for HIPAA 5010 news, tips and training
We've got your back.
Availity will be open Monday,
Jan. 2, 2012, fully staffed
and prepared to give you the
outstanding service you expect.
Availity 5010 Migration Timeline
*Payments from payers will continue during this time, but payment noti�cations (835s) will be delayed.
29T H U R S D AY | D E C 30F R I D AY | D E C 31S AT U R D AY | D E C 1S U N D AY | J A N
Normaloperations*
Plan to send alltransactions by close ofbusiness 12/29 to avoidprocessing delays*
Transactionssuspendedafter 6 p.m.EST
• Normal operations resume.• 4010 transactions will be increasingly up-converted to 5010.• Providers should confirm correct use of NPI and PO Box �elds, regardless of version sent.
Transaction processingresumes.
Web Portal & B2B(key-entered or
received from a PMS)
EDI(large batch/
direct connection)TRANSACTIONS SUSPENDED
INTERMITTENT/SELECTEDOUTAGES
www.availity.com 3
Will we still receive payment from health
plans if Availity suspends processing?
On Dec. 29 and 30, as we migrate to
5010, payments will be processed from
your payers as usual, but the related
835 transaction acknowledgement may
be delayed until Jan. 1, after our 5010
change-over is complete.
Availity recommends that you talk with
your practice management software
vendor to make sure certain billing
processes aren’t dependent on these
835s, which could affect your month-
end or year-end closing process.
Will there be a cut-off date when transactions have to be in the new format
to be processed?
Availity will continue to up-convert
or down-convert your transaction to
accommodate the preference and
readiness of the receiver (health plan),
as we’ve been doing since January
of this past year. Availity does not
have any current plan to discontinue
up-conversion of 4010A1 files on a
specific date.
Even though Availity has no planned
date for discontinuing 4010 processing,
we strongly recommend that you
convert to 5010 as soon as possible.
What happens when Availity “up-converts” or “down-converts” a
file from 4010 to 5010 or vice versa?
When Availity “up-converts” a file,
it maps data from a submitted
4010A1-formatted transaction to the
corresponding required data fields on
the 5010 record format, to the minimum
standard necessary to comply with
5010 transaction requirements.
Conversely, if a provider sends a
5010 formatted file to a payer not
yet equipped to handle 5010 files,
Availity will “down-convert” the 5010
file by mapping data from it to the
corresponding necessary data fields
in the older 4010A1 format.
Either or both scenarios may be used
to complete a round-trip information
exchange between a submitter and
payer. In every event, it is Availity’s
goal to present the information to the
end-customer in whichever version
they prefer to process.
What is a dual-mode payer?
A payer continuing to accept both 4010
and 5010 is considered “dual-mode.”
The number of dual-mode payers will
decline steadily in 5010, as enforcement
of the 5010 mandate takes effect.
In the case where a payer is dual-
mode, Availity makes no up- or down-
conversion of the file.
Why might my up-converted file
get rejected?
If the receiving payer is 5010-only (not
dual-mode), all incoming transactions
to them must be 5010 compliant.
Availity’s conversion tool will
automatically pass your incoming 4010
file “up” to 5010, for 5010 validation.
If Availity can apply auto-corrections
to make your file 5010-compliant, then
we forward the file to the payer for
processing as usual.
FAQ continued on page 9
Still feeling a little antsy? Just click Free Training in the Availity portal for
live and on-demand 5010 training.
4 Availity inFocus | Dec/Jan 2011-12
You see it every year: As people
abandon their healthful living
routines and winter cold sets in,
a stuffy flight is enough to land
a visitor in your office—sick.
Help treat your sick traveler with
Availity®CareProfile®, and access
critical patient history for visitors
without local medical records.
WithCareProfile,yougeta
longitudinal care record that provides
up to 24 months of your patient’s
carehistory—supplementingself-
reported history that could be
incomplete or inaccurate. Because
CareProfileisbasedonapatient’s
claims, you can view health care
services rendered by all their health
care service providers, including:
• Professional,hospitaland
emergency room services
• Radiologicalandlaboratory
services and lab results
• Prescriptionmedicationhistory
• Immunizationhistory
• Patient-specificcaremessages
and alerts
Get started now
YouwillneedyourPAAto
grant access, as appropriate, to
CareProfile.1 If you’ve already
been assigned access, simply
select CareProfile from the Availity
services menu on the home page,
then select your patient’s health
plan.Freewebinarsareavailable—
just click Free Training at the top of
any page.
1Primary Access Administrators (PAAs) can assign or revoke user access to CareProfile by clicking Account Administration | Maintain User in the Availity menu. For more information, click Help at the top of the Availity portal and search for the “Maintaining Users” topic.
Spotlight On: CareProfileSick travelers with no health records? No problem.
Learn more about the CareProfile and how it can help you.
New
In addition to the current, local
health plans, authorized users
also may access CareProfile
records for members with Blue
Cross and Blue Shield (BCBS) plan
coverage in Florida, Illinois, New
Mexico, Oklahoma and Texas.
www.availity.com 5
5010 Quick TipsA one-page reference for important 5010 changes
Update your address book to keep payments flowing
• Whensubmitting5010-complianttransactions, the billing provider and service facility addresses must be complete, physical street addresses and can no longer be a PO Box or a lock box.
• Todirectremittances(payments)toa different address, use the pay-to-provider, name and address fields.
• Dependingonthehealthplan,youwill receive warning messages or rejection errors for incomplete street address fields.
Put 9 on the line
• With5010-complianttransactions,the billing provider and service facility addresses must be complete street addresses and can no longer be a PO Box or a lock box.
• Completeisdefinedasincludingthe full 9-digit ZIP code: traditional 5-digits plus the extra 4 digits for localized mail delivery.
• Dependingonthehealthplan,youwill receive warning messages or rejection errors for incomplete street address fields.
• TheCentersforMedicareandMedicaid Services (CMS) will be validating the ZIP+4 sent in for both
billing provider and service facility. Please ensure you are properly registered in the PECOS system for Medicare before changing this data in your PM system.
• CheckouttheZIP code directory look-up and plan to update your address fields and PM system accordingly.
* Prior to making changes in the practice management system, providers should validate their credentialing and/or enrollment with health plans to ensure payments will not be negatively affected.
Minutes matterFor professional claim
transactions, the reporting of anesthesia minutes was revised. In 4010, payers could require the anesthesia time be reported as the total number of minutes or as units. In 5010, you can only report the total number of minutes. Units are no longer an acceptable format for reporting anesthesia time. Any requirements by a payer to submit anesthesia start and stop times in the 5010 transaction will be noncompliant with the TR3.
Billing provider clarification• In5010,abilling
provider must be a provider of health care services and can no longer be a
billing service or clearinghouse. New clarifications to the definition of a billing provider include: • Billingprovidersmustnowbe
those entities that perform services that are reimbursed by health plans.
• Makesureyouareusingthecorrect NPI for your organization. This must be the same NPI identifier for all trading partners.
• TheTaxIDmustbesentfortheBilling Provider on the claim.
Patients are a virtueAs your payers become capable of sending and
receiving 5010-formatted transactions, please remember that, for health plans that assign a unique identifier per member, the individual must be listed as a subscriber. The patient is not listed on the transaction.
For health plans that assign a number to the entire family, follow these rules:• Thepolicyholderisalwayslistedas
the subscriber.• Ifthepolicyholderisthepatient,the
patient is not listed in the transaction.• Ifthedependentisthepatient,
they are listed as the patient in the transaction.
6 Availity inFocus | Dec/Jan 2011-12
““
case fiLes Revenue management consultant says electronic access kept client in business
As a revenue management
consultant for multiple small
physician practices in Florida,
Merrilee Severino, CPC, CMM, CPM,
has seen the incredible impact of
electronic administrative tools using
the Availity multi-health plan network.
“Many small practices would not be
in business today if this didn’t exist.”
Severino teaches one and two-
physician practices to use available
information technology to simplify
the administrative aspects of running
a practice. “It’s frustrating for a
small practice when they don’t have
an easy way to get the information
they need from health plans,” says
Severino. “They emphasize quality
patient care, but when they can’t get
the information they need to manage
the business, they don’t get paid, and
that has a negative impact on their
ability to stay in business and help
people get better.”
She said that one of her past clients
avoided bankruptcy because of the
electronic access to health plans.
“This provider was the victim of some
fraudulent activity that left her in a
negative cash flow situation. She had
a number of bills that needed to be
submitted to health plans and she
could only afford one employee to help
manage the business end of things.”
In order to keep her practice running,
she needed to be paid right away.
Having electronic access to eligibility
and benefits, claims submission,
and claim status, the patient cost
estimator and online payment
collection tools were the keys to
keeping her in business. “We were
able to eliminate days of work and get
right to the information we needed
to get her paid. She was able to get
to cash flow positive in a matter of a
couple of weeks. It really saved her
business,” says Severino.
Has Availity helped your practice?
We want to hear from you! Send us
your story and you may be featured
in a future “Case Files” story. Email
us at [email protected].
I have been billing for 13 years and used several different clearinghouses, and
Availity is the best. I own a billing service and recently added a new doctor
who was using another clearinghouse. I told him if he wanted me to be his
biller, he would have to change from his current clearinghouse to Availity.
With easy-to-read reports and great technical support, Availity is my
clearinghouse of choice.
Twyla Huffman, OwnerSan Angelo Medical Claims Service | San Angelo, TX
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www.availity.com 7
Enhancement and update news from Availity
Availity message center retired Availity has retired the Message
Center and removed its tab from
the Availity menu. The retirement
of this feature provides Availity the
opportunity to offer an enhanced site
design for a quick and easy Availity
portal experience.
To view retired or updated help
topics, please review the "What’s
New and Changed" Availity help topic.
Updates: Quick hitsHere’s a summary of what else is new
from Availity:
• Registrationservicesandsecure
messaging is now available for
Anthem providers in California,
Colorado and Nevada
• BlueCrossandBlueShieldplan
providers in Florida, Illinois, New
Mexico, Oklahoma and Texas can
now submit Availity® CareProfile®
inquiries to those plans, outside a
member's Blue plan home state
• 5010transactionsforAnthem:
Eligibility and benefits and claim
status inquiry
• Registrationservicesand
secure messaging now available
for Blue Cross and Blue Shield
of Georgia providers
• 5010transactionsforBlueCross
and Blue Shield of Georgia:
Eligibility and benefits and claim
status inquiry
• Availity® CareRead® is now
available to Anthem Blue Cross
and Blue Shield providers in
Indiana
• Healthplansaddmore5010
Web transactions:
•Aetna
• AnthemBlueCrossin
California
• AnthemBlueCrossand
Anthem Blue Shield plans in
Colorado, Indiana, Kentucky,
Missouri, Nevada, Ohio,
Virginia, and Wisconsin
• BlueCrossandBlueShieldof
Georgia
•MedicalMutualofOhio
•UniversalHealthCare
• BlueCrossandBlueShieldof
Kansas City
•FloridaHealthPlans
•Humana
•KaiserFoundationOhio
•PreferredCarePartners
•USFamilyHealthPlan
OCTOBER
For complete updates:
NOvEMBER
what's new
Get up-to-the-minute info on 5010 transactions
Find out which payers support
what transactions in 5010 format
by visiting availity.com/5010.
Search by health plan or by partner.
8 Availity inFocus | Dec/Jan 2011-12
A "Real" Gift for Your Companycontinued from page 1
but after implementing RealMed
as their RCM solution, realized
such significant efficiencies that
the practice redeployed its staff
to follow up on unpaid claims
three times: at 30, 60 and 90
days. Automated revenue cycle
management, coupled with best
practices in claim follow-up, allowed
the practice to significantly reduce
its timely filing denial rate, and
greatly reduce time to payment. The
practice saw a 75-percent reduction
in days in accounts receivable, from
28 days to less than seven days.
It was one of many benefits the
anesthesia practice realized—
benefits that translated to saved
time, faster payment collection, and
a better way of doing business—
which benefit everyone. If you
aren’t automating your revenue
cycle, your administrative staff, and
even some clinical staff, may be
spending more time on process
and less time than they’d like on
patients. So give everyone a “Real”
gift with RealMed.
Your FastestPath to Payment
© 2012 RealMed Corporation. All rights reserved.
www.realmed.com
Health care providers turn to RealMed, a complete revenue cycle management solution, when they want real results:
•Fastercashflow and fewer days in accounts receivable.•Automatedeligibilitychecking during claim submission.•Improvedoperationalefficiency including fewer claim errors and fewer denials.•Betterunderstandingofworkflowpatterns, to help you maximize revenue.
www.availity.com 9
5010 Update Centercontinued from page 3
If Availity can’t know with 100%
certainty how to populate the 5010
required fields, (e.g., a missing NPI
is something that can’t be populated
by Availity), the transaction gets
rejected by Availity because the
receiving payer requires 5010
compliant transactions only.
If your file can be made compliant by
our conversion tool, it gets sent ahead
to the payer. But, since each payer
has the ability to customize its edits
for processing, your valid 5010 file
sent in by Availity may still encounter
a rejection by the payer, based on the
payer’s own criteria. Payers may relax
or tighten their custom edits as more
and more of their network providers
begin submitting in the new format.
Depending on the type of error, your
error messages are provided on
either the IBR or the EBR, to help
you correct your submission.
Availity offers fast, easy training
on 5010 transactions
Interested to learn more about
submitting Availity portal
transactions in the new 5010 format?
Availity offers several live and on-
demand training options to help you
become familiar with changes. For
more information click Free Training
in the Availity portal.
events
Jan. 4 greenway Regional user group Las vegas, nv
Jan. 17 greenway Regional user group chicago, iL
Jan. 18 iht2 health summit scottsdale, aZ
Jan. 18 wisconsin hfma 2012 mega conference wisconsin Dells, wi
Jan. 20american academy of orthopaedic surgeons and Karen Zupko & associates Present coding and Reimbursement workshops
Dallas, tX
Feb. 8 san antonio mgma annual education conference san antonio, tX
Feb. 20 himss 12 annual conference & exhibition Las vegas, nv
Feb. 21 georgia hfma summer institute greensboro, ga
Feb. 23 indiana hfma winter institute carmel, in
Stop by our booth and say "hello" at one of these upcoming events.
10 Availity inFocus | Dec/Jan 2011-12
tRaining
Optimizing Your Clinical Workflow with Technology
Explore ways to improve your day-to-day operations by using technology, and learn about qualifying for ARRA/HITECH meaningful use incentives—all without being a computer jockey. Industry expert Rosemarie Nelson will share how high-performing groups integrate patient portals, EMRs and registries, e-prescribing, automated reminders and devices into and around the patient encounter.
Understanding and Implementing ICD-10 in Physician Practices
ICD-10 expert Robert Tennant will teach you the basic parameters of ICD-10-CM. He’ll discuss how the associated coding changes will affect your organization—and how you and your team can stay ahead of the curve.
Do you want to gain a competitive
edge in your field, but need flexible
learning options? Availity’s Health
Care Business Expert Series delivers
continuing education via national experts
in health care information technology.
Unlike your portal training webinars—
which continue to be offered at no
cost to you—the Health Care Business
Expert Series is a fee-based service
that will equip you with knowledge
needed to broaden your skills, train for
expanding job responsibilities, fulfill
continuing education requirements,
or simply enhance value to your
employers. Sign up for your free
Availity Learning Center account,
then log in to purchase one or more
webinars for $129 per session.
Learn from top industry experts and
make your practice more efficient,
without ever leaving your office. You’ll
be CEU application-ready*, and will
receive a certificate of completion
after the session.
Please note that the fee for Availity
Learning Center courses applies only
to our continuing education courses.
Training on how to use the Availity
portal is always available to you at
no cost.
Register now!
*AAPC members receive 1 CEU for each webinar.This program has the prior approval of AAPC for 1 continuing education hour. Granting of prior approval in no way constitutes endorsement by AAPC of the program content or the program sponsor.
Get more from Anthem BCBS on Availity
Want a faster, more efficient way to access Anthem Blue Cross and Blue Shield value-added services, like secure messaging, specialty pharmacy and imaging precertification? You can avoid two logins and two sites by registering for these services on Availity. Just follow these simple steps:
1. Log in to Availity and click My Account, Anthem Services Registration. If prompted, select your organization.
2. In the display field, click Non-Registered Users. 3. Enter the user Anthem Blue Cross and Blue
Shield User ID (also known as the EAM ID) in the field provided and click Register.
Training on using these Anthem services is available through the Availity Learning Center. Just click Free Training at the top of any page in the Availity portal to find out more information on upcoming webinar schedules.
#1
Introducing the Availity Learning Center
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www.availity.com 11
Across2. More people are traveling outside of
theUSforthistypeofholiday4. The kind made of sugar, not wood 5. Forpancakesoracough8. ThisDaisyBBgunmakesafamous
appearancein“AChristmasStory”10. An empty sock11. A popular medical myth claims this
happens at a higher rate on Christmas12. Thought to be the source of a large
amount of body heat lost in the cold14. You are likely to make, and fail to keep,
one of these 15. This Celtic holiday signifies the
reversal of the longer nights and shorter days
17. January’s birthstone19. Known for nutty health benefits22. Roast on an open fire23. The type of tree you decorate24. A winter medicine cabinet is likely to
be stocked with these
Down1. ASeinfeld-bornholiday“fortherest
of us” 3. You’ll head to the gym in January for it6. Why turkey causes sleepiness7. Good for a kiss, poisonous if
swallowed9. Popularholidayplantinhomes,
churches and offices13. HaveaBowlonNewYear’sDay16. Don’tforgettoleavetheseforthebig
man in the red suit18. This winter festival was initially
celebrated by Germanic people20. Candles, holiday lights and Christmas
trees cause several hundred of these each year
21. You may do this type of eating during the holidays
22. Thousands of injuries occur each year as a result of these shopping companions
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Availity and RealMed wish you a happy, healthy holiday season. Watch for another issue of Availity inFocus in the New Year!
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