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Eradicate enrollment? - Thought Leaders; healthcare Electronic Data Interchange

Nancy Ham

Anyone employed in any aspect of healthcare delivery is in the midst of what has been dubbed "administrative simplification" and everything it entails for day-to-day operations. Unfortunately, a critical element is still missing.

Today, the payer electronic data interchange (EDI) enrollment process serves as a provider's formal request to begin exchanging transactions with the payer. This process is responsible for contractually binding the provider and payer to certain conditions.

Enrollments for noncommercial payers, however, such as Medicare, Medicaid, CHAMPUS, Rail Road Retirement and the Blue Cross Blue Shield plans are undeniably more complex than those of the commercial plans, and they almost always require a provider or officer's signature. For providers today, enrollment with these plans results in excessive paperwork, unnecessary delays in electronic submissions for all stakeholders and a lower overall percentage of EDI. If there is hope of simplifying the business of healthcare while increasing the percent of EDI--a goal clearly implicit in the legislation itself--then the process of enrollment in these plans must be improved.

What's Wrong?

Although there have been some historical attempts at simplification, such as the Centers for Medicare & Medicaid Services' enroll merit simplification as recently as July 2003, enrollment processes remain convoluted. Payer EDI enrollment continues to be:

Redundant. Those providers wishing to sign up "all payer" with a clearinghouse are often required to complete four separate enrollment forms (Medicare, Medicaid, Blue Cross Blue Shield and CHAMPUS) along with the service contract and trading partner agreement with the clearinghouse. In the state of Georgia, this adds up to more than 28 pages of contracts.

Time-consuming. The entire enrollment process can take between two and 12 weeks to complete per payer. A significant amount of this time is wasted in a predominately paper-based mechanism that could easily be improved with technology readily available to all. This becomes more complicated when more than one clearinghouse is involved in the chain. Time is lost when:

* paperwork is mailed to providers after contracts have been received (some forms can be downloaded, but other states require originals only);

* documents sit in a provider's office waiting for signature;

* a provider mails paperwork back to the clearinghouse for submission;

* a clearinghouse mails paperwork to the payer; or

* pending approvals must be tracked down to resolve delays within the payer organization. This requires phone calls to find the right person and to track down paperwork. To finalize approval, some payers send a written confirmation via U.S. mail, tacking on more days to the cycle.

Assuming the paperwork is correct, four to six weeks are wasted with this paper-shuffling. Even if all the forms are downloaded and mailed directly to the payer from the provider office, it can still take up to three weeks to complete the approval process. If the paperwork isn't correct, the cycle repeats and greater delays ensue.

A barrier to free market competition. With a process that is so painful and an enrollment that is closely tied to the clearinghouse, providers find themselves reluctant to change clearinghouses, even if they can get better pricing or services elsewhere.

Inconsistent. Ninety-four percent of commercial plans don't require EDI enrollment at all. For large commercial payers not requiring enrollment, electronic claims can be received as soon as a clearinghouse has certified the provider's test file, creating efficiencies for everyone involved. If commercial plans can operate so efficiently, why can't other payers?

What's the Answer?

There are two primary solutions. Enrollment can be simplified with adjustments in process and acceptance of technology (i.e., make a bad process better), or the enrollment process can be eradicated completely.

Enrollment simplification. There are two key elements needed to simplify enrollment. The first is universal language. There are common requirements with all payer EDI enrollments. Obtaining consensus on universal language that can be used for all service agreements between providers and clearinghouses opens the door for potential bypass of payer EDI enrollments. A cursory review of EDI enrollments has shown many similarities that would make this less challenging than it seems, such as the assignment of the clearinghouse as agent, the agreement to exchange accurate and true data, and the agreement to protect privacy and confidentiality.

The second is provider signature alternatives. Adjustment to accept electronic signatures would entirely omit the delays seen from snail mail. Even better, if the provider assigned the clearinghouse power of attorney for the purpose of EDI enrollment, the delays seen from obtaining signatures would virtually disappear.

Enrollment eradication. Why not? There is no shortage of paperwork oil file. The physician and the plan have contracts, the plan and the clearinghouses have contracts, the clearinghouses and the physician have contracts. Business associate agreements are now wallpapering almost everyone's office from one end of the nation to another. If each of these elements is confirmed in place, isn't this sufficient?

Enough Is Enough

In the future, the enrollment process will gain new layers of complexity. Some commercial payers that have not required enrollment will begin to do so for transactions like electonic remittance advice and real-time inquiries. Before this happens, there is a chance to improve the system as it exists today and to establish a simpler mechanism in which these new enrollments can be included.

In his book, "Leadership is an Art," Max DePree says, "We cannot become what we want to be by remaining what we are." That's especially true in this instance. Everyone wants administrative simplification. Unfortunately, it will never be achieved by ignoring the problems with enrollment today and, in turn, allowing the process to worsen over time. Making this type of change will not be easy. A joint effort will be required by all stakeholders, including the AMA, state medical associations, state Medicaid directors associations, CMS and the Blue Cross Blue Shield Association. Now is the time for us to support that change.

Nancy Ham is the president of ProxyMed Inc., headquartered in Fort Lauderdale, Fla.

COPYRIGHT 2004 Nelson Publishing
COPYRIGHT 2004 Gale Group

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