You may wonder why you can’t use the electronic data interchange (EDI) files that you send out and receive to give you meaningful reporting and collection information.
The bad news is that it is your fault. The good news is that you can fix it. Here are the issues in bullet points:
- You can’t find your data, or not all of it.
- You can’t read the data.
- You can’t organize the data.
- You can’t match up the data to your internal accounting system.
You can't find your data
The flow of EDI looks something like this for all healthcare entities:
So why can’t I find my data? First there are usually more than one system and or vendor transmitting billing data. Physician practices are usually on a different electronic health record than hospitals. In fact, there are two electronic billing file types for billing files, one type conforms to the UB-04 billings for hospitals and the other file type conforms to CMS 1500 professional billings. You may even have specialty billings being created by systems for practices like behavioral health. I have never received a complete set of billing data files on the first try.
Next are issues around payment files. First, there are always a number of payers that are not providing electronic payment files. This is usually because the volume of claims did not warrant the facility signing up to receive electronic payment files. Secondly, there may be a weak link between patient financial services and the IT department on signing up to receive EDI files.
Finally, and most commonly, is that there are multiple processing entities providing files. Combined with the issue of hospital and physician claims is the fact that individual third-party payers can mandate that you can only receive files from their vendor of choice. Some even require that you download payment files from their website. The worst payer I have ever seen in most respects is Illinois Medicaid. They release payment files for download, but often have not paid the balance on the remittance advice (they are constantly out of money but want to appear to be processing claims).
You can’t read your data
The first hurdle reading EDI files is that they are sent in a format called “record set.” The current required record set is the “5010” record set. These files have special control characters that tell you how to read the data. In their raw form, each EDI file comes as a single line of data. To make it easier to read, your processing vendor may add breaks between the parts of the file and they may not.
Next, different vendors and third-party payors will give you the data with slightly different variations of data and still call the files “837” or “835” files. As noted above, sometimes line breaks will be added to the files. Some payers may use different special characters that are to be used to read the data. You usually need a custom application to handle these variations. Yes, we can help you with this.
You can’t organize your data
You asked for your billing and payment files. IT put them in a folder on your shared drive. You got a program to “read” the EDI files (CMS has free one). You are all set right? Now the issue is how can you find a single claim in this mountain of files. Not only do you need a program to read the files, you need to create database of all your claims so you can really use the data. Hint here-This is where you call us!
You can’t match your data to your accounting system
When you register a patient, they should get a unique Medical Record Number or “MRN.” Your internal accounting system assigns a new account numbers to a patent related to each admission. When transmitting electronic bills-the account number for the admission is sent with the bill so when the payment comes back it can automatically posted to the account. So far so easy right? Well your IT department usually adds other identifiers before and after the account number in the electronic claim for their own internal purposes. They may add “001” in front of the account number. They may add numbers after the account number to indicate the number of bills submitted. They may even add the patient’s medical record number to the account number. IT often handles account numbers differently for different payers. Let’s take an example. A patient is admitted and given the account number 123456. You sent a first bill to Medicare and it was rejected. You billed the claim to Blue Cross and it is paid. The patient has a MRN of “BYNY456.” The unique identifier sent with the first claim is “00112345601 BYNY456.” The “001” was added because your system adds this as a prefix to all claims submitted. Since this was the first claim, “01” was added to the account number as a suffix. Finally, a space was added and the MRN to the end of the claim. When the claim to Blue Cross is transmitted, it has the account number “00112345602 BYNY456.” Now “02” has been added to the end of the account number and before the MRN to indicate it was the second claim on the account being submitted. When the electronic payment is received, your IT department has to ‘map” the payment to the account by stripping away the “001” prefix then use the next 6 digits to post the claim to the account, ignoring the MRN and “01” and “02” added by the the system after the account number.
If you want to use the parsed data, you will have to understand this ‘mapping” as well. You may even want to see if your IT department can modify how it creates account numbers to make your life easier.
Timothy Powell, CPA CHCP