While mandates have been in place since 2009, the adoption of Work Comp EDI has been slow to materialize. A November symposium in St. Paul, Minnesota was focused on gathering ideas and momentum for the move from paper to Electronic Data Interchange (EDI) in the Workers Compensation industry.

The day long symposium called “Meeting Mandates, Making the Connection: Workers’ Compensation Electronic Health Care Transactions” was organized to bring together stakeholders to talk about the challenges of the transition. Minnesota Department of Health and Minnesota Department of Labor and Industry put on the symposium. The purpose of the gathering was to solicit feedback on the challenges of work comp claims processing and the reality of the transition to electronic transmission. Many different stakeholders were present; hospitals, clearinghouses, insurers, clinics, employers, third party administrators, and government entities. There was a broad consensus on the core of the issues impacting the industry:

  • Transparency of trading partners is lacking
    • Payer IDs are inconsistent, multiple clearinghouses in-between provider and payer, no history of transaction routing for held up claims
  • Lack of detail in 835s for Work Comp EDI
    • Vague/inconsistent denials and inability to post payments because of limited information provided
  • Lack of compliance in providing electronic claims processing from providers/payers
    • Across the board participants found that only 10-15% of providers/payers are using EDI for work comp, the vast majority still go on paper
  • Inability to secure the claim event number
    • Providers are unable to access basic billing information which delays claims and creates heavy overhead costs for calling up work comp companies to get necessary claim information for processing
  • Work Comp EDI attachment standards
    • Agreement that sending medical records attachments to payers is a huge issue. Even when sending electronically, the claims may be dropped to paper by some payers. This can result in delayed payment as the records are requested again and again. There are also issues with the multiple clearinghouses that create “hops” in the EDI transaction. Payers claim they didn’t receive attachments but there is little accountability after the claim leaves the providers clearinghouse.
  • Denials and acknowledgements are not consistent
    • Payers, clearinghouses use their own coding, such as insurance naming. This lack of consistency increases complexity of working denials.
  • Payers have many subsidiaries and not always clear where to send claims for processing
    • Claims rejected on the basis that they were sent to wrong division, but no information on where to send, which state, division etc. is provided.
  • Clearinghouses using standards vs. “inventions”
    • Because of a lack of standards, clearinghouses are creating their own rules (inventions) and making other parties comply which is problematic. For problem solving there is no way to identify who or what to call for complex Work Comp EDI issues between provider clearinghouse and payer clearinghouse

Unfortunately, there were not a lot of short term solutions and while there are groups at the state and national level making progress, getting changes implemented takes years. This is evidenced by the fact that EDI work comp law was enacted in 2009 and providers and payers are far from compliant. We are confident we will continue to see more progress on the continuum to EDI in workers compensation in 2015.

Outsource Receivables is using the latest EDI technology for Workers Compensation claims to ensure clean, efficient, and timely processing that maximizes reimbursement. If you would like more information on how this technology can benefit your clinic give us a call.

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