Emdeon Connection

Emdeon Acquires EquiClaim to Expand its Payment Integrity Solutions Offering

2011-07-29T10:00:00.005-05:00

We are excited to announce Emdeon has acquired EquiClaim, a leading provider of post-payment healthcare claims audit and recovery services for commercial and government payers, from MultiPlan. EquiClaim’s programs enable Emdeon Payment Integrity Solutions to offer healthcare payers a more comprehensive suite of prospective and retrospective payment integrity services. EquiClaim’s offerings, now named Emdeon Audit and Recovery Services, are designed to provide credible and objective programs that help payers reimburse providers appropriately and provide a foundation for both parties to improve the payment process.

Emdeon now offers commercial and government payers:
• Robust payment integrity services with enhanced audit capabilities, enabling retrospective recoveries for improper payments

• Improved payment integrity through enhanced intelligence, for claims review in accordance with medical billing guidelines, contractual obligations and reimbursement rates and policies

• Recovery audit contractor (RAC) services, specifically for the government sector, in support of the program the Centers for Medicare and Medicaid Services (CMS) introduced in 2005 and recently rolled out to state Medicaid programs

• More tools to help reduce general and administrative costs, by improving the accuracy of the claims payment process and the recovery of improper payments

• Enriched, comprehensive payment integrity solutions that include both pre-adjudication validation (clinical code validation, provider verification, predictive and rules-based fraud detection software and analytics), as well as post-adjudication validation (special investigative unit services, post-payment audits for contract compliance, and hospital bill audit and diagnosis-related group (DRG) audit services

With this acquisition, Emdeon furthers its goal of helping payers make appropriate payments as well as working to make sure providers receive reimbursements from payers that meet negotiated, contracted rates.

How Emdeon Audit and Recovery Services Can Help with ICD-10 Transitions
CMS reports that mandated claims coding changes (from ICD-9 codes to new ICD-10 codes) will likely cost the health insurance industry more than $1 billion. CMS also anticipates an initial 10 percent increase in the number of claims rejected for improper coding.

Adding EquiClaim's capabilities to Emdeon's Payment Integrity Solutions offers Emdeon's payer customers more tools and expertise to help meet this regulatory-driven challenge. It also further positions Emdeon to help its government and commercial customers' initiatives promote cost-effective healthcare and reduce fraud, waste and abuse (FWA).

EquiClaim was one of the first subcontractors for CMS's RAC program. As mentioned above, CMS introduced the RAC program in 2005 and recently rolled it out to state Medicaid programs under Section 6411 of the Patient Protection and Affordable Care Act. The RAC program is a cost-containment effort intended to reduce improper payments within the Medicare and Medicaid programs. It also aims to identify process improvements that could reduce or eliminate future improper payments.

EquiClaim's capabilities give Emdeon more ways to help its payer customers resolve payment issues arising from increasingly complex provider contracts, reimbursement methodologies and claim payment policies. Emdeon’s end-to-end prospective and retrospective payment integrity solutions can help payers be more efficient and improve cash flow.

To discover more about Emdeon Payment Integrity Solutions, visit www.emdeon.com/paymentintegrity.

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Pre-Payment Fraud Detection and its Impact on the Bottom Line: A New Payment Integrity White Paper

2011-07-29T09:30:00.006-05:00

The phrase, “An ounce of prevention is worth a pound of cure” aptly applies to a movement within the healthcare payment industry: Fraud, waste and abuse (FWA) prevention. Because of lean budgets and compelling cost analyses, payers are motivated to find payment integrity solutions that can identify FWA before paying erroneous claims. For optimal aberrance detection, consider adopting a proactive, preventive approach.

This white paper can help payers determine the best ways to protect themselves against FWA. It demonstrates the benefits of proactive, in-stream claims review and illuminates powerful preventive resources, to understand how to limit unnecessary claim payment, potentially saving significant time and money.

Specifically, this white paper details:
•How shifting to a pre-adjudication or pre-payment fraud detection solution can yield significant financial impact

•Characteristics of an effective pre-payment FWA management solution

•Organization, system and process implications of adopting a pre-payment FWA management solution

To read this white paper or to discover more about Emdeon Payment Integrity Solutions, visit www.emdeon.com/paymentintegrity.

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Industry-leading education sessions from AHIP’s Institute 2011

2011-07-29T09:00:00.005-05:00

Emdeon hosted several speaking sessions during America’s Health Insurance Plan’s (AHIP) Institute 2011 Conference June 15-17 in San Francisco. If you weren’t one of the more than 3,000 AHIP attendees, or if you missed one of Emdeon’s six in-booth speaking sessions, you can watch these presentations online.

Emdeon’s in-booth presentations included:

•Fraud, Waste and Abuse Prevention: An Industry Perspective, presented by: Louis Saccoccio, JD, Executive Director, National Healthcare Anti-Fraud Association (NHCAA) and Kelli Garvanian, Payment Integrity Solutions Consultant, Emdeon

•How to Save $9 Million Preventing Fraud, Waste and Abuse: A HealthMarkets Case Study, presented by: Taryn Risucci, Vice President, HealthMarkets

•The Next Generation Health Plan: Intentional Transformation, presented by: David Gallegos, SVP of Consulting, HTMS, an Emdeon company,
and Nancy Wise, VP of Planning and Strategy, HTMS, an Emdeon company

To learn more about these topics or to access other Emdeon presentations, including white papers and webinars, visit www.emdeon.com/ahip2011speakers.

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Simplify Your Business with Two Bigger, Faster, Better Solutions from Emdeon

2011-07-29T08:30:00.003-05:00

Have you ever seen a duck gliding on a lake? It's a serene image: As sunlight gleams on the duck's iridescent feathers, it skims smoothly and seamlessly on the glass-like water. Yet just underneath the surface, the duck's feet paddle quickly, furiously, relentlessly—in constant, concerted effort to keep moving forward. It takes tremendous work to look that effortless.

Emdeon is much like that duck; our systems work ceaselessly, and our people are endlessly innovating, creating bigger, faster and better ways to simplify the business of healthcare. As our partner, you enjoy the smooth reliability of the more than 100 solutions Emdeon offers. You can conduct business with seamless functionality because we're paddling nonstop to save you time, money and effort managing the revenue and payment cycle.

However, at Emdeon, "bigger, faster, better" is never enough. Our goal is to give you the services and support you need to lead. We are constantly improving, working to advance our existing solutions and pinpoint new ones, to enhance your ever-growing, ever-changing business. We're pleased to report the proverbial paddling has paid off once more in the form of two major innovations: Emdeon's data center additions and our new, best-in-class print technology.

Emdeon Data Centers
We invite you to look below the surface to get a glimpse of all that goes on— not only to maintain the single largest financial and administrative information exchange in the U.S. healthcare system—but also to take it to new heights.

Our data centers deftly, reliably and securely transmit an enormous number of information exchange points and transactions at any given minute, on any given day—such is the business of healthcare. Yet the volume of data exchanged is not nearly as impressive—or important—as what we can now do with this data.

Rather than keep data chained together through separate business rules and processes, as previously required, our technology now allows us to create data mash-ups, combining and aggregating data to make information more useful and nimble.

Here's a quick look at the advanced capabilities this technology can enable.

For payers:
•Decrease call center and other operational costs by minimizing errors or omissions in provider claims
•Detect potential insurance fraud before claims payment
•Offer providers preventive patient care messages using the patient’s medical and pharmacy histories
•Eliminate pounds of paper received by mail or fax

For providers:
•Get paid faster—using electronic claims that are auto-corrected and/or enriched with eligibility data to increase auto-adjudication rates
•Receive remittance advice or payment estimates within seconds of filing an electronic claim
•Easily obtain comprehensive, accurate patient medical and prescription histories
•Monitor patients’ adherence to disease management protocols during defined periods

In bringing the new data centers online, we have streamlined many of our business processes, reducing the potential for human error. Automating these processes allows us to more accurately measure performance and anticipate issues before they become a problem. Already we have seen a steady decrease of calls at our call center and increased customer satisfaction.

Our new, massive data centers are "state-of-the-art" in every sense, exchanging data at lightning speed to eliminate downtime and increase productivity. With hundreds of miles between them, these facilities are redundant yet independent, to ensure all data is secure, safe and accessible—without interruption.

These centers feature:
•55,000 square feet, with 2,000 servers
•Two petabytes of storage (That’s 2,000 terabytes!)
•20+ load balancers (10+ redundant clusters)
•900 Microsoft Windows servers
•350 IBM AIX Unix servers
•500+ VMWare virtual guests
•450 databases
•100 percent growth potential

Unparalleled Printing Advancements
We have introduced the Pitney Bowes^® IntelliJet^™ 30 printing system, for the next generation in on-demand printing technology and patient communication production. As one of only three such systems in the world, Pitney Bowes IntelliJet^™ takes the idea of "fast, high-quality printing" to stratospheric levels. With amazing 120x600 dpi output at 1,380 pages per minute, there is virtually no limit to what providers can create, design and produce for patient communication.

This new printing technology offers:
•Advanced print quality for razor sharp, vibrant patient statements
•Full-color, two-sided statements with exceptional resolution—1200 x 600 dpi
•Print rates of 1,380 pages per minute (400 feet of paper per minute)

With this new capability, Emdeon ExpressBill is more responsive than ever, and can produce patient statements quickly, regardless of quantity. We can also easily update the statement design and content and print statements on demand—eliminating costs and waste associated with traditional methods.

In addition, patient statements now enter the mail significantly sooner than before, through logical presorting that combines postal codes before printing, eliminating USPS sorting delays. Emdeon can print batched statements in full color—pre-sorting them—so statements hit the mail immediately upon completion. Statements mailed sooner often lead to faster payment.

At Emdeon, we know we are doing our job when you see "the duck gliding across the water" and you don’t have to worry what’s required to keep things moving. With these exciting changes, Emdeon has made it possible for you to go about your business more easily, while we keep "paddling" to our next innovative solution.

To discover more about Emdeon’s innovations and for a video tour, please visit www.emdeon.com/innovation.

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HIPAA Simplified Update

2011-07-29T08:00:00.002-05:00

We are pleased to announce Emdeon has met requirements of the Electronic Healthcare Network Accreditation Commission's 5010 Readiness Assessment Program. Emdeon scored 100 percent, further demonstrating our ongoing commitment to help ensure HIPAA 5010 compliance.

In addition to this recognition, Emdeon continues to help our payer partners and submitters successfully migrate to the X12 5010 and NCPDP D.0 versions of HIPAA transaction standards. We have updated our gap analysis documents to include the recent 5010 Errata changes and have enhanced our 5010 systems and products to support these changes. Errata versions of the gap analysis documents are available at the HIPAA Simplified website under 'Downloads'.

We strive to provide updated and accurate information for HIPAA 5010 readiness. Answers to the most commonly asked questions about HIPAA 5010 are below.

Q. How is Emdeon preparing for HIPAA 5010 testing?
A. Emdeon is testing and implementing 5010 standards with submitters and payers. The late release of the Errata changes to the 5010 transaction standards further constricted the already narrow 5010 testing and conversion window. Nevertheless, Emdeon has initiated submitter and payer testing on all 5010 transactions, as you can see in the list below.

Q. Which Errata tests are being conducted?
A.
•837 Professional claims
•837 Institutional claims
•837 Dental claims
•835 ERAs
•270/271 Eligibility verification

Emdeon is also testing with submitters and payers the Final Rule version for HIPAA X12 transactions the Errata revisions did not include:
•276/277 Claim Status
•278 Referral/Authorization

Emdeon's guiding principles for the 5010 program are to sponsor a rational, orderly and realistic transition while protecting provider cash flow and successful payer EDI penetration.

Q. What is the timeline of events?
A. Emdeon is committed to supporting 5010 standard transactions on all of its products and services prior to the compliance date (January 1, 2012). Emdeon is in 5010 production with early implementer submitters and payers and is also in 5010 testing with many of our trading partners.

Q. Where can I find additional HIPAA 5010 information?
A. Emdeon has created a valuable resource, HIPAA Simplified, that is available to all industry stakeholders at www.hipaasimplified.com. HIPAA Simplified is a one-stop, online resource that features gap analysis, business-level documentation, webinars, transition timelines and customer testing information.

Thank you for trusting Emdeon as your information source for HIPAA readiness. We work diligently to deliver solutions that help our submitters and payers seamlessly meet industry regulations.

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An Inside Look at HTMS, Emdeon's Newest Payer Solution Offering

2011-03-18T10:37:00.007-05:00

Through the acquisition of Healthcare Technology Management Services (HTMS) in March 2010, Emdeon now offers consulting services to help payers innovate, solve problems and optimize performance in an ever-changing healthcare environment. Acting as a strategic partner, HTMS, an Emdeon Company, helps healthcare clients develop and implement technology solutions to align with healthcare trends and each client's overall business strategy. HTMS empowers payers to achieve technology-enabled transformations.

Mike Comick, HTMS co-founder, explains what makes HTMS unique and shares the company’s focus for 2011 in this question-and-answer session.

Q. How did HTMS get started and what was your vision for the company?
A. Mike Weiher and I started HTMS in 2000– each of us has more than 25 years’ experience as healthcare consultants. Through the years, we have seen demands for healthcare consulting change. In response, we wanted to create a company that offers productive, experienced staff with specific skill sets and expertise that work variable lengths of engagement to meet particular client requirements. Our strategic approach includes reality-based interventions with practical solutions and measurable outcomes.

Q. You two are healthcare veterans! How does HTMS differ from other consulting companies?
A. We reduce the risk inherent to consulting by getting the people a payer really needs to do the job. We make sure our consultants have the specific expertise a payer wants and are engaged only at certain times, when the payer needs them. This helps us keep roles competitive and minimizes excess costs.

Another thing that makes us different is our employee model. We have 80-110 people in the field…a 40/60 ratio of employees to contractors. Our consultants have deep health industry knowledge. They have experienced a lot of the challenges organizations face, so they understand that payers may have limited time and resources, out-of-date systems, antiquated processes and diverse perspectives.

Q. Targeted staffing and optimal efficiency must be especially popular with payers these days. Which successes make you especially proud?
A. We focus on healthcare technology and operations at the executive level. As numerous regulatory and market‐driven healthcare IT changes converge, payers have to assess their existing platforms and respond to these changes. HTMS specializes in researching and assessing the healthcare IT software and service vendor market for “best-of-breed” solutions. Our leadership team has a unique blend of experience, including senior executives from healthcare organizations and leading market research firms.

Key Focus Areas Include:
• Core claims and administrative systems
• Care management
• Automated member acquisition
• Healthcare reform
   -5010
   -ICD-10
   -MLR
   -Meaningful Use
   -Health Benefit Exchange

Q. Those are all very important topics for payers. How do you typically engage a payer client?
A. Our goal is to determine what the client wants– to peel the onion, so to speak. We consider education and market awareness to evaluate how a particular payer compares to its peers, and establish what it would take for the payer to compete with its leading competitors. Then we assess whether the client is willing or able to commit resources– financial, system and time- or if they can procure what’s needed to reach the top in that market. Once we’ve determined that, we analyze the payer’s strategic plan and identify gaps. Afterward, we implement and execute, testing all the systems and applying industry best practices.

Q. How do you evaluate a payer’s peers?
A. Each month HTMS distributes a survey with 8-15 questions about critical issues plans face today. The responses we receive provide benchmarking information and help us assess how payers are faring in a certain area, such as ICD-10 preparedness. Once we aggregate the data, we create a summary of our findings, which we share in a knowledge brief. We send a link to these online results when we survey payers about the next month’s topic. HTMS has conducted the surveys for years and has gained valuable insight and perspective into the payer market. We look forward to expanding the surveys and building our recipient list.

Previous surveys covered topics such as:
• Program management and organizational prioritization
• ICD-10 readiness among health plans
• Health plans struggling with 5010 compliance

Q. The survey feedback sounds especially useful. But, are there privacy concerns?
A. No. Survey responses and results are shared, but no proprietary information or identifying characteristics are given. The information gleaned from these surveys is NOT used for sales, but rather to give HTMS better insight into the payer marketplace. Interested in participating in the HTMS Executive Survey program? Email research@htms.com and request to be included in our next survey.

Q. That will likely reassure our readers. How will HTMS help payers respond to recent legislative changes in healthcare?
A. In light of ongoing healthcare reform, regulatory changes and the consumerism trend, payers need help assessing their current IT strategies– now more than ever. The HTMS team provides strategic support of technical remediation, such as the transition to the new version 5010 and pharmacy D.0 transaction formats, through the delivery of education and training workshops. For example, HTMS can help clients identify the impact of changes to workflow, systems, coding and clinical guidelines they will face in the transition to new ICD-10 code sets.

Q. ICD-10 impact is at the top of many payers’ concerns. What’s one area you’re passionate about personally?
A. While my coworkers at HTMS recognize me for my healthcare expertise, I also get a lot of attention for my love of the New England Patriots. With HTMS based in Indianapolis, Indiana, home to the Indianapolis Colts, my choice of teams baffles a lot of my Colts-leaning coworkers. They do, however, enjoy debating the topic with me during football season—or just about any time!

Q. Well, that can certainly divide an office! What’s your primary focus for 2011?
A. The Patriots starting the season off strong! Oh, you mean at HTMS? The evolution of healthcare reform and its subsequent implications for payers. We’ll start by evaluating a payer’s IT portfolio management systems to determine whether their technology and/or internal systems meet new and future requirements. Then, we’ll establish remediation and system replacement and, if applicable, recommend system and organizational investments.

We plan to pay special attention to:
• Commercial plans
• Traditional Medicaid-only plans
• Specific healthcare reform issues in CA and MA

For more information about HTMS, an Emdeon company, including survey results and white papers, visit www.HTMS.com.

Michael Comick, Partner
As principal and co-founder of HTMS, Mike Comick leads HTMS' business development initiatives and industry intelligence and analytics practice while directing automated member acquisition and care management service offerings. He focuses on strategic consulting services, including IT and business planning, system assessments and procurements, and implementation services. Previously, Mr. Comick was a vice president with First Consulting Group's Los Angeles office, specializing in core claims and administration software applications. He joined FCG after working with Charles J. Singer and Co./Gartner Group as the practice leader for core system market research. In that capacity, he published the ‘Managed Care System Vendor Guides,’ the ‘Managed Care System Win/Loss Analysis’ and the ‘HMO MIS Budget Report,’ a comparative analysis of the leading managed care systems in the industry today. Using this analysis, Mr. Comick facilitated numerous workshops and education sessions with both the payer and at-risk provider markets. He has a degree in economics. When he’s not working, Mike collects and wears a lot of Hawaiian shirts—and enjoys greeting colleagues with an enthusiastic, pirate-style “Arrrrrgggghhh!”, a tradition that began at a company meeting several years ago and remains today.

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ICD-10: Moving Beyond Compliance to Leading Edge Innovation

2011-03-18T09:42:00.011-05:00

by Benjamin Heck, MHA

“This massive effort …calls for all healthcare stakeholders to completely rework operations for claims processing, provider contracting, medical management, quality reporting, information technology, disease management and other business and healthcare activities. ”
—Karen Ignani, President and CEO, AHIP www.AHIP.org

ICD-10 implementation may be one of the biggest challenges payers will face in the next five years. Though often seen as a compliance issue, ICD-10 offers a new way of doing business for those who embrace and plan for the change, instead of just responding to it. Given its wide-ranging impact on multiple payer departments and supporting technology, planning a strategic approach to imminent ICD-10 requirements is critical.

To develop this approach and gain a competitive advantage, payers must first:
• Understand ICD-10’s impact on virtually all payer information systems, operations, medical policy, staff, rules and processes

• Realize compliance is not just about programming system changes – it is about re-engineering business processes to harness the clinical detail ICD-10 provides
• Compress timelines and implement new processes quickly, to maximize the power of ICD-10 and ensure a smooth transition

• Communicate closely with provider networks to minimize negative transition effects and maintain goodwill

ICD-10 coding can offer many benefits, including:
• More accurate payment for new procedures. The American Medical Association (AMA) estimates the health insurance industry could save $777.6 million in unnecessary administrative costs by improving claims processing accuracy by just one percent. Role-specific training on the new, expanded code sets and meticulous system configuration that automates claim processing can reap a valuable return. To ensure accurate, consistent communication, payers and their provider networks should examine contracts to capitalize on the more specific codes.

• Fewer fraudulent claims. Implementation of ICD-10 code sets will not eradicate healthcare fraud. However, the specific, granular nature of these codes creates more accurate data, enabling rapid detection of questionable billing patterns and fraudulent claim submissions.

• Fewer rejected claims. Rejected claims cost both providers and health plans significant money. Incomplete documentation and duplicate claims submission cause most claims rejection. Better provider education and more accurate billing will lead to more prompt payment processing.

• Improved disease management. ICD-10 codes can help case managers better identify candidates for disease management programs, thereby improving member health by preventing or delaying serious complications.

• Better coordination of response to disease outbreaks. Through common coding and reporting, healthcare institutions can identify and respond to international disease outbreaks faster and more effectively.

Critical Deadlines:
There is no indication the government will move or relax the following dates. Wishful thinking is not a compliance strategy; strategic planning is the only way to remain competitive.

• January 1, 2012—HIPAA 5010 Compliance. Plans must be able to receive claims electronically using the X12 version 5010 and NCPDP Version D.0 standards.

• October 1, 2013—Plans must comply with ICD-10 rule sets.

Benjamin Heck, MHA
Benjamin Heck has more than 15 years of experience in the healthcare industry, providing IT and health plan operations consulting. He has led, and been involved with many successful core system implementations for a variety of healthcare payer organizations and has experience in information systems, project management, consumer-driven health, business process outsourcing (BPO), Medicare Advantage, ICD-10 and health payer operations. Prior to joining HTMS, he worked as a director of operations for several Mid-West health plans. Mr. Heck currently serves as a partner with HTMS, an Emdeon company, and leads the system assessment, procurement, implementations and ICD-10 practices.

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Common Sense and Common Ground Can End Healthcare Gridlock

2011-03-18T09:37:00.003-05:00

by Emdeon CEO George Lazenby

In 2011, our country must tackle three serious but potentially conflicting objectives to return to economic health: 1) We must decide the fate of healthcare reform; and, simultaneously, 2) shrink the federal budget deficit; and 3) reduce taxpayers’ burden.

The stakes could not be higher as the 112th Congress debates repealing or modifying the Patient Protection and Affordable Care Act of 2010. Recently, the Congressional Budget Office announced the federal budget deficit for 2011 will be at least $1.5 trillion—a deficit record no one wanted to see broken.

Against this challenging background, it is easy to assume we will be stuck in healthcare gridlock. But I believe there are common sense actions we can take today, with support from across the political spectrum, that can help lead us out of gridlock and get us back on track to being a healthier nation with a brighter economic outlook.

To learn which three steps Lazenby believes could help the U.S. healthcare industry start reversing billions in annual healthcare losses, visit: www.emdeon.com/fraudprevention, and download this article from the Bureau of National Affairs’ Health Care Fraud Report.

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Payer-Focused Webinars Can Help You Stay Competitive

2011-03-18T09:17:00.006-05:00

Emdeon offers several educational, payer-focused webinars that give you access to industry experts and ideas that are revolutionizing the payer marketplace. Emdeon’s 60-minute webinars are designed to keep you informed, analyze industry trends and share new and innovative approaches to the payer business. Use the information provided to help your organization improve efficiency and maximize profits with these leading-edge webinars.

Available Webinars:
Payment Integrity
• Building Your Payment Integrity Arsenal: Protecting Your Members, Providers and the Bottom Line
Recent healthcare legislation dramatically altered the payer landscape, making fraud, waste and abuse management a top priority. Success in this new environment means adapting to regulations by adopting leading edge technology that is flexible, reusable and meets government requirements, all while optimizing efficiency. An integrated, holistic approach to fraud detection and prevention combines predictive, data-driven analytics with expert analysis and investigation, to help payers meet guidelines, reduce unnecessary payments and improve profitability. This live webinar featuring IDC analyst Janice Young offers insight into a changed healthcare marketplace—one that necessitates another look at powerful new fraud, waste and abuse detection technology.

Access this webinar:
http://www.emdeon.com/contactform/shortform.php?promoCode=PIARSENAL929

• Maximize Savings and Minimize Lost Dollars Using an Integrated, Holistic Approach to Payment Integrity
Learn how to protect your organization from healthcare fraud, waste and abuse using Emdeon Payment Integrity Solutions. Emdeon’s multi-layered fraud-detection system enables accurate identification and investigation of suspect claims both prior to and after claim adjudication and payment. Benefits experienced by shifting from a retrospective, pay-and-chase model to a proactive, preventive paradigm are examined and explored. The session concludes with a question and answer session and discussion around the need for an integrated Payment Integrity methodology.

Access this webinar:
http://www.emdeon.com/support/webinars/2010NHCAA/

ICD-10
• ICD-10: Strategies for Assessing and Addressing Impact
It is critical that healthcare organizations recognize the transition to 5010 and, subsequently, ICD-10 affects virtually all people, processes and technology in an enterprise. In most cases, payers must research and modify all processes/work flows, systems, coding, clinical guidelines and interfaces to comply with ICD-10 standards. Payers must address ICD-10 not only to adhere to HIPAA regulations, but also to remain competitive in the market. This webinar outlines ICD-10 and 5010 implications, offering an assessment strategy that may help payers make these transitions smoothly.

Access this webinar at:
http://www.emdeon.com/contactform/shortform.php?promoCode=WEBINARSAAI

Care Management
• Evolving Care Management Strategies: Patient-Centered Medical Home
The concept of a Patient-Centered Medical Home (PCMH) is hardly a new one –a form of the concept was often practiced a few generations ago. However, as healthcare progressed, approaches changed and the PCMH approach virtually disappeared. With the influx of technology over the last decade and increased pressure to reduce healthcare costs while improving outcomes, a modernized PCMH is one way to improve care management and coordination that is gaining traction.

Access this webinar at:
http://www.emdeon.com/contactform/shortform.php?promoCode=WEBINARECM

• Improving Care Coordination by Utilizing Existing Technology
Improving outcomes and decreasing healthcare costs are two key challenges in healthcare today; enhancing care coordination can help solve both. The severity of the problems demands involvement from stakeholders throughout the healthcare community, and yet the complexity, costs and often resulting inconvenience associated with some technological solutions often leaves stakeholders feeling underserved and overwhelmed.

Access this webinar at:
http://www.emdeon.com/contactform/shortform.php?promoCode=WEBINARICM

• Synchronizing Care Coordination and Pay-for-Performance Initiatives
Health plans, the healthcare provider community and patients can all benefit from the quality improvements and cost reductions involved with tighter patient care coordination. Pay-for-performance initiatives are often designed to incent providers to improve their patients’ health by encouraging adherence to evidence-based guidelines and use of the most appropriate treatments. Linking care coordination to pay-for performance initiatives requires understanding the intended goals and using technology that enables a broad spectrum of healthcare stakeholders to communicate patient information.

Access this webinar at:
http://www.emdeon.com/contactform/shortform.php?promoCode=WEBINARSCM

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Increase New Electronic Transaction Utilization!

2011-03-18T09:14:00.003-05:00

Have you added a new electronic transaction lately and aren’t seeing ideal utilization levels yet? It may be because your providers’ system vendors have not implemented and turned on the transaction within their systems.

Emdeon now offers you a resource to help improve new transaction utilization with those providers who connect through a system vendor. Our new Payer Transaction Request webpage educates providers on the steps necessary for requesting these new transactions from their vendors. It even offers a letter template that can be downloaded and placed on the providers’ letterhead to be mailed or emailed to their vendor.

Interested? Simply direct your providers to this site: http://www.emdeon.com/payertransactionrequest/ and you’ll be one step closer to increased new transaction utilization!

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Interactive Care Management: A Framework for Healthcare Quality and Cost-Containment Initiatives (An Emdeon White Paper)

2011-03-18T09:04:00.007-05:00

The Fundamental Problems that can cause Population Health Strategies to Fail

The American healthcare system today is facing a multitude of problems - a number of which are attributed to failed or less than successful population health strategies. Costs are out of control, and the quality of American healthcare has been challenged when compared to several other developed countries. Approaching these problems, health plans rely on a spectrum of tools, including Prevention and Wellness, Disease Management, Case Management and Utilization Management, and more recently, accountable care organizations, patient-centered medical homes, and pay-for-performance initiatives. These initiatives attempt to reduce short-term and long-term costs while improving the healthcare delivery process and outcomes. Each of these strategies relies on healthcare stakeholders, such as doctors and health plans, exchanging and analyzing information that prompts different actions by physicians and patients. Furthermore, the effectiveness of the strategies is often subject to meaningful adoption and utilization by healthcare providers and the openness of patients to participation and behavior change. Although each of these programs can work in tandem to improve quality and tackle cost challenges, total population health strategies often fail to be as effective as they could be in part because they are not tied together in a new conceptual framework called Interactive Care Management.

To learn more about Interactive Care Management, read the rest of the Emdeon white paper at: http://www.emdeon.com/resourcepdfs/Moving_Forward_with_Reform_WhitePaper.pdf

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Moving Forward with Reform: The Health Plan Agenda for 2011 and Beyond

2011-03-18T09:01:00.003-05:00

It has been nearly a year since health reform has passed, yet health plans are still trying to keep up with the specific provisions of the health reform law and how they will be clarified in the future. Managed Care Executive Group, Health Dialog and HTMS, an Emdeon company, jointly issued a new report that examines critical issues, priorities and challenges for regional health plans in the post-reform era. The report, entitled,“Moving Forward with Reform: The Health Plan Agenda for 2011 and Beyond” is based on information gathered from a survey of more than 55 health plans.
The report captures several concerns of regional health plans and offers insights into actions that may help health plans address these concerns. The survey provides a mid-term check-in on how the MCEG’s annual Top 10 List of Issues for health plans remains relevant.

To download a copy of, “Moving Forward with Reform: The Health Plan Agenda for 2011 and Beyond,” please visit www.healthdialog.com/go/MCEG.

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Congress begins task of merging five health reform bills into one

2009-10-27T11:06:00.013-05:00

After months of touting the transparency of health reform negotiations, Congressional leaders retreated behind closed doors to start the task of merging together the five major healthcare reform bills that have passed out of various Committees. As healthcare annual spending tops $2.4 trillion, the stakes are high as Congress faces conflicting pressures to expand coverage and curtail spiraling costs.

A handful of major issues and many smaller ones remain unresolved. The two chambers disagree on how to pay for the legislation, with the Senate preferring a tax on high-value insurance policies as the main revenue-producing measure, and the House favoring a surcharge on millionaires. Liberal Democrats want to penalize companies that do not provide coverage to their employees; moderate Democrats would take a less punitive approach. And many lawmakers are concerned about the affordability of insurance policies Congress would require people to buy under an individual mandate.
So the question remains– can consensus be reached in a Congress that remains sharply divided on the details of reform?

A Closer Look at the Debate

In the House
Leaders in the House have proclaimed they can produce a public plan using Medicare rates, but it is unclear they really have the 218 votes required for such an approach. On the other hand, the Medicare for Everyone, or “Medicare Part E,” rebranding of a public option has managed to sway at least some moderate House Members, as has confirmation of a deal struck in the Energy and Commerce Committee to eventually increase Medicare rates in rural areas. What is clear now is that a “robust,” federally-administered, nationwide public plan will be included in the House bill.

The House does intend to include some of the “fees” initially proposed in the Senate Finance bill, with keen focus on the medical device fee. We understand that Speaker Pelosi told concerned Members that the House tax would be $20 billion, assessed to profits (rather than fees assessed to all revenues, as in the Senate bill).

Without a pathway to a final bill or comprehensive Congressional Budget Office (CBO) scores, House floor action appears unlikely before the week of November 9. Given its ability to move legislation more quickly, however, the House could be on the floor as late as the week of November 16 and still pass their bill prior to Thanksgiving recess.

In the Senate
Progress in the Senate continues at a slow pace. Despite positive statements by principals, negotiations at the staff and Member level have been difficult and sometimes contentious. While no “deadline” for the talks has been set, leadership has privately directed that final legislation be scored by the CBO and ready for the floor by November 9. Several key staff are increasingly skeptical that the deadline can be met.

While Senator Olympia Snowe has not shifted her position that a “trigger” must be associated with any potential public option, other key moderates appear to be softening. Senator Ben Nelson and others have expressed openness to an approach that would allow states the ability to opt out of a federally-run public plan. While there are not yet 60 votes for the opt-out approach, the middle ground of the conversation does appear to have shifted meaningfully to the left, with a federally backed public plan more likely than before. Use of Medicare rates by the public plan(s) continues to be highly unlikely in the Senate, or in the final bill.

Major Provisions

Following is an overview of the provisions in each of the major bills that passed out of Committee earlier this year. While the merged bills could look quite different, it is useful to see varying provisions being considered as the next phase of the debate unfolds.

Senate Finance
• Cost projected to be $856 billion over 10 years
• Creates health care affordability tax credits to help low and middle income
families purchase insurance in the private market
• Provides tax credits for small businesses to help them offer insurance to their
employees
• Allows people who like the coverage they have today the choice to keep it
• Reforms the insurance market to end limits on pre‐existing conditions and health status
• Eliminates yearly and lifetime limits on coverage
• Creates web‐based insurance exchanges that would standardize health plan
premiums and coverage information to make purchasing insurance easier
• Gives consumers the choice of non‐profit, consumer owned and oriented plans
(CO‐OP)
• Standardizes Medicaid coverage for everyone under 133 percent of the federal poverty level
• Requires adoption of standardized electronic administrative transactions to drive efficiency, reduce errors and lower costs

Senate Health, Education, Labor, & Pensions (HELP)
• State health insurance exchanges
• Government-run, public health insurance option to compete with private insurers to drive costs down
• Individual insurance mandate, with some exceptions for those who cannot afford coverage
• Employers with 25 or fewer employers also exempt from penalties
• Prohibiting insurers from denying coverage based on their health status
• Promoting quality through financial incentives for providers
• Coverage of preventive health services
• Extending coverage for dependent adults until age 26
• No lifetime or annual limits on individual or group health insurance policies

House Tri-Committee (Committees on Energy and Commerce, Ways and Means, and Education and Labor)
• Creation of a public insurance option
• Expanding access to health insurance
• Standardized benefits packages
• Provisions to end premium increases or coverage denials for "pre-existing" conditions
• Eliminating co-pays for preventive care
• "Affordability credits" to make premiums affordable
• Caps on out-of-pocket expenses
• Employer mandate- pay or play
• Guaranteed catastrophic coverage

Senate Finance Comes Out Strong on Administrative Simplification

All of the major healthcare reform bills include provisions that support healthcare administrative simplification, but the Senate Finance language remains by far the strongest. Specific provisions include:

• Timeline for accelerating existing HIPAA transactions
• Adds electronic funds transfer (EFT) as a required transaction
• Single set of operating rules for eligibility verification, claims status, claims remittance/payment, and EFT developed by a qualified non-profit entity, reviewed by NCVHS
• Rule to create unique health plan identifiers
• Requirement that health plans file a certification statement by Dec. 2013 that their data and information systems comply with the most current published standards for four transactions: eligibility verification, claims status, claims remittance/payment and EFT
• Requirement that by2014, no Medicare payment under Part A or Part B be made other than by EFT or an electronic remittance

Emdeon Supports Sensible Policies, Practical Solutions

Emdeon supports and promotes sensible public polices and practical solutions that make healthcare efficient. Our goal has been to help reframe the healthcare reform debate and focus on actions we can take today to take costs out of the system. Key areas like administrative simplification, program integrity/fraud and abuse, third party liability cost avoidance and public beneficiary management offer billions in potential annual savings.

The U.S. Healthcare Efficiency Index™, launched by Emdeon in 2008, identified $300 billion in savings over 10 years from automating the most basic healthcare administrative transactions. Emdeon has worked to raise awareness of these potential savings that can free up dollars to pay for delivery of care or offset costs of longer term reforms.

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Member Management...moving efficiencies upstream in the healthcare cycle

2009-10-26T15:30:00.008-05:00

by Sanju Pratap, Director of Payer Product Management at Emdeon

Healthcare is experiencing a retail-style transformation. Benefit, health and consumer oriented information are converging and being delivered at the point of care. Because of this, the point of healthcare service has evolved into a very teachable and effective moment- shaping behaviors and influencing outcomes... all of which directly contribute to downstream administrative and medical cost savings for payers.

In a market where efficiencies equate to increases in the bottom line, payers continuously look for additional solutions where they can do more with minimal resources. Emdeon has recently launched a Member Management product category - a suite of solutions designed to greatly reduce downstream administrative and medical costs by leveraging Emdeon’s eligibility-driven solutions and provider reach, payers’ benefit information and the provider workflow to create healthcare efficiencies upstream in the process.

Imagine using one silver bullet, your members’ eligibility & benefit data set, to address multiple market challenges upstream, at the point of service. That’s what payers can do with Member Management! Here are just a few of the key features and benefits:

• Address multiple challenges with minimal and streamlined development & operational investment
• Improve member care management
• Enhance provider, member and employer group relations by enabling transparency, self service and a reduction in claim denials
• Comply with growing federal & state regulatory compliance – ie: HIPAA, CORE and State regulations
• Increase EDI & auto-adjudication rates
• Reduce waste & cost via proactive coordination of benefits and pre-adjudication services

Eligibility, authorizations, claim status and other related real-time inquiries are often viewed as just another communication requirement for interaction with providers. But by leveraging that information and workflow to enable real-time transactions, payers can use those transactions to also address the evolving pre-care administrative and medical information needs.

Emdeon has helped payers ranging in size from 1,000 to several million members leverage Emdeon eligibility-based solutions to achieve HIPAA compliance, improve self-service via increased EDI transactions and web based portals, and increase auto-adjudication rates. These same payers are beginning to leverage existing solutions and operational processes to provide care management, transparency, coordination of benefit solutions and achieve compliance for the growing regulatory requirements.

Emdeon Member Management is a comprehensive approach fueled by the convergence of core healthcare transactions, benefit information management, constituent engagement and care coordination to address as many healthcare challenges as possible upstream in the process by leveraging existing provider, member and payer workflows.

As the marketplace evolves, consumers will be empowered with information to make better decisions regarding how they use and pay for healthcare services. Providers will use clinical data to deliver evidence based care and new tools to effectively manage their business. Payers will use existing proven solutions to support constituent performance-driven solutions to support a healthy population.

To be competitive in such a transformed marketplace, payers will need to remain competitive, achieve more with less, and realize the vision of a healthy population via synergistic solutions.

Emdeon is leveraging existing applications and workflows to address the rising market challenges upstream in the process…thereby greatly reducing downstream administrative & medical cost related challenges. For more information on Emdeon’s Member Management payer solutions, visit www.emdeon.com/membermanagement or contact spratap@emdeon.com.

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Emdeon Partners with Susan G. Komen for the Cure® for Unprecedented Education & Awareness Campaigns

2009-10-26T15:19:00.005-05:00

Thanks to Emdeon real-time technology and the real-life information of the Susan G. Komen for the Cure®, healthcare providers across the country will be able to print out practical, useful information for patients during appointments, potentially empowering thousands of people with deeper knowledge about how to detect and respond to risk factors, face challenges and get help.

Emdeon and Susan G. Komen for the Cure are partnering to revolutionize in-office, teachable moments by making breast health literature readily available to patients through their healthcare providers. The printable materials include topics such as “Breast Cancer Risk Factors”, “When You Discover A Lump”, and “Sexuality and Intimacy” in both English and Spanish formats. There is no limit on the number of times the providers may print the disease prevention and wellness materials.

These materials are currently available through the web-based software solution, Emdeon OfficeTM, a solution that enables healthcare providers to conduct everyday administrative transactions, including patient eligibility/benefits verification, claim submission, referrals, authorizations and pre-certifications for care. It is currently in use in professional offices representing nearly 100,000 healthcare professionals across the country.

In addition to exposing thousands of healthcare providers to readily accessible, print-quality downloads, Emdeon is engaging in another campaign to turn America’s mailboxes “pink” this October. During the month, Emdeon’s print and mail facilities will print outgoing consumer healthcare statement envelopes with a hot pink awareness message that reads, “Are you Inspired to Save a Life? Find out how at www.komen.org/inspire.” Since Emdeon sends millions of consumer statements each month, millions of people will be thinking pink this October.

For more information on this partnership, visit www.emdeon.com.

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Encouraging Electronic Claims Submission Saves Money- up to $175,000 annually!

2009-10-26T11:18:00.011-05:00

Did you know that most providers cite the top barrier to submitting electronic claims is simply a lack of information? Many times providers just need to be informed that a certain claim type can be accepted electronically, and sometimes it’s even as simple as informing the provider of the correct Payer ID. That’s where Emdeon Accelerated Growth Program for Claims comes in. By leveraging our extensive provider reach with our analysis of your organization’s electronic and paper claim volumes, Emdeon identifies EDI opportunities and customizes a growth program to increase electronic utilization among connected, submitting providers, and conversion to electronic for paper-only submitting providers. Payers who actively participated in a growth program in 2008 realized an average annual savings of nearly $175,000!*

Emdeon’s Accelerated Growth Program for Claims can impact your bottom line by increasing EDI transactions, improving auto-adjudication rates and moving your organization and the industry closer to paperless administration. Specific and measurable growth plans designed by Emdeon help payers capitalize on EDI opportunities to increase electronic adoption and utilization among providers. If your organization has an Emdeon Managed Gateway agreement, you may even be eligible to receive a complimentary growth program.

So take further advantage of your Emdeon partnership today– based on your provider claim submission trends, we’ll identify barriers and educate your providers through phone outreach campaigns, seminars and co-branded marketing campaigns. Contact your account manager, give us a call at 877.EMDEON.6 or email moreinfo@emdeon.com to get you on the road to saving more money today with Emdeon Accelerated Growth Program for Claims!

*Average annual savings of payers whose combined EDI/paper claim volume was 100,000-1,000,000 per month

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Top 10 reasons Payers and Providers are experiencing more WOW with Emdeon Vision for Claims Management

2009-10-26T11:10:00.007-05:00

Payers, providers and vendors all across the country are experiencing the WOW factor of Emdeon Vision for Claims Management. If you are a payer who processes claims through Emdeon, your customer service representatives can have access to this innovative, valuable reporting tool– don’t wait, enroll today. Here are 10 great reasons why you should enroll!

1. It's Fast!

Nearly 95% of all Emdeon Vision searches return search results in less than 5 seconds.

2. It's Easy!

Thanks to the simple user interface of Emdeon Vision, most users require NO training to use Emdeon Vision. For those users that do require training, Emdeon has created detailed training videos, a very thorough user guide, and online help available within Emdeon Vision.

3. It's included with your current service!

The ability to track claims in Emdeon Vision is complimentary for payers AND providers. No registration fee. No monthly fee. Consider it a free gift from us to you.

4. Experience a common view from one data source.

Emdeon Vision is used by Emdeon internal support, payers, vendors, and providers, all using data from a single source. With everyone using the same data, problem resolution is increased greatly.

5. Eliminate software or hardware maintenance.

Emdeon Vision is a web-based claim-tracking and reporting tool that can be used from any Internet-enabled computer. No new hardware or software is necessary.

6. Access historic claim data.

Emdeon Vision contains 15 months of claim data for all constituents (e.g. payer, provider and vendor). In this way, historical claim information may be reviewed for trends. All 15 months of historical claim data is available immediately upon registration. **

7. Eliminate software or hardware maintenance.

Emdeon Vision is a web-based claim-tracking and reporting tool that can be used from any Internet-enabled computer. No new hardware or software is necessary.

8. Improve provider relations.

Emdeon Vision can improve provider relations because providers can access their claim data easier and more quickly than through paper reports. This allows providers to “help themselves” rather than calling payers or vendors for claim information.

9. Reduce paper claim attachments.

With the introduction of Workers Compensation Attachments and Medical Claim Attachments in late 2009, Emdeon Vision will help payers and providers reduce the cumbersome and timely process of mailing paper attachments. The process is as simple as using Emdeon Vision to identify claims that require attachments, linking the attachment to the claim (a process much like attaching a document or picture to an email), and uploading the claim and attachment to the payer. As with everything in Vision, handling attachments is fast and easy.

10. Did we mention it is FREE?

Don’t wait– experience the WOW– learn more by visiting here or simply email us at moreinfo@emdeon.com to get started!

**Contingent upon length of time claim volume has been sent through Emdeon – if volume has been funneled through Emdeon for less than 15 months, availability is for the length of time volume has flowed through Emdeon.

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Simplify the H1N1 vaccine administration claim processing with Emdeon

2009-10-26T11:00:00.001-05:00

Emdeon is now enabling billing for the administration of the H1N1 vaccine on medical claims from pharmacies. We have the capability to make the process transparent to payers by integrating these claims into payers’ existing EDI medical claim feeds. Refer pharmacies to eRx Network, an Emdeon company at 1-866-erx-network and you’ll be on the road to greatly simplifying this complex process.

Whitepaper Exposes Healthcare Administrative Waste

2009-02-25T11:23:00.034-06:00

Practical Steps for Cutting Healthcare Costs through Existing Infrastructure & Collaboration

The U.S. economy transmits over 18 billion electronic payments each year, yet approximately half of all healthcare financial transactions are still paper-based. Costs of paper, printing, postage and labor for manual processes in healthcare are estimated to add up to nearly $30 billion a year in waste. As healthcare reforms are considered in Washington and in all 50 states, administrative savings represent a bright spot—low-hanging fruit—that could help pay for longer-term reforms. To help inform this dialogue, Emdeon, in cooperation with the Center for Health Transformation, unveiled an important whitepaper at the HIMSS 2009 Annual Conference in April. The whitepaper, "Taking the Paper Out of Paperwork: How Electronic Administration Can Save The U.S. Health System Billions", looks at the gaps in the industry that keep it dependent on manual processing—and offers practical steps for breaking this costly and inefficient cycle. "In these trying economic times, combined with the specter of unsustainable spending, Medicare insolvency and runaway growth in Medicaid, we must find those IT solutions that can not only save lives but can also lower costs," said Former House Speaker Newt Gingrich, founder of the Center for Health Transformation. For more of the Speaker's message, view the video foreword to the whitepaper. The whitepaper provides a step-by-step roadmap for both payers and providers and highlights best practices that are delivering tangible results today. This pragmatic approach leverages technology and infrastructure that already exist—and provides a vision for a new kind of industry collaboration. Recommendations outlined in the whitepaper include:

For Payers
* Develop and pilot reimbursement programs that reward quality healthcare practice and results, including electronic information exchange.
* Ensure all future information technology development is done according to industry standards.
* Collaborate around multi-payer functionality, understanding that providers want a single resource for interacting with health plans.

For Providers
* Keep abreast of federal funding opportunities for health information technology.
* Include process re-engineering for an electronic end-to-end eligibility, claims and payment process in electronic medical record (EMR) implementation strategies.
* Work with medical societies and specialty groups to advance national standardization goals.

Download the whitepaper.

Emdeon Readies for Implementation of New HHS Rules

2009-02-25T10:47:00.029-06:00

HHS Issues Final Rules on HIPAA v5010/NCPDP D.0 and ICD-10 Implementation; White House Action Puts Timeline in Question
Early in January 2009, the Department of Health and Human Services (HHS) finalized two important sets of rules regarding EDI transactions. The rules, set to go into effect in March 2009, could be subject to change after the White House issued a memorandum stating it will further review any regulations that have been published but have not yet gone into effect.

HIPAA v5010/NCPDP D.0
On January 16, 2009, HHS issued its Final Rule on modifications to administrative simplification regulations under the Health Insurance Portability and Accountability Act (HIPAA). These rules update the HIPAA electronic transaction standards to the X12 standard, Version 5010 and the National Council for Prescription Drug Programs (NCPDP) standard Version D.0. The Final Rule changed the compliance date from April 2010 (in the proposed rule) to January 1, 2012.

The Final Rule introduces a compliance timeline for HIPAA v.5010/NCPDP D.0. Under the new HHS compliance timeline:
• Covered entities should have designed, developed and tested their own systems prior to January 1, 2011.*
• Trading partners should have tested the interchange of transactions and implemented connections using the revised standards by January 1, 2012. *
* These dates could be subject to change pending review of the Final Rules by the White House.

ICD-10 Implementation
HHS also issued final rules for implementing a revised version of the International Classification of Diseases Clinical Modifications and Procedure Coding System (ICD-10 CM and ICD-10 PCS) as a HIPAA standard code set. The agency received numerous comments expressing concern about the move to ICD-10, but it determined that the transition was necessary to address challenges with Medicare. The compliance deadline for ICD-10 is October 1, 2013. *

* This date is also subject to change pending White House review.

Emdeon Readies for the Transition; Gap Analysis Guides the Effort
HHS issued proposed rules in August of 2008 and received extensive input from industry organizations and individual payers, providers, vendors and others. Emdeon worked with several key industry and standards organizations to prepare comments and also submitted its own comments on behalf of its customers and business partners.

Since then, Emdeon mobilized an experienced team of subject matter experts to analyze the potential impact of the regulations and to develop a comprehensive approach to the transition.

The first step was to conduct a data gap analysis for all of the HIPAA transactions that Emdeon supports. Project teams were formed for each transaction type for Version 5010 and NCPDP Version D.0. Specific transactions include the following:

X12: 5010
• 837 Health Care Claim: Professional
• 837 Health Care Claim: Institutional
• 837 Health Care Claim: Dental
• 835 Health Care Claim: Payment/Advice
• 270/ 271 Eligibility/Benefit Inquiry and Information Response
• 276/ 277 Health Care Claim Status Request and Response
• 278 Health Care Services Review– Request for Review and Response (Referral Certification and Authorization)

NCPDP: Pharmacy
• D.0 Claims & Encounters
• D.0 Eligibility
• D.0 Referral Certification & Authorization
• D.0 Coordination of Benefits

Emdeon’s internal gap analysis between 4010A1 and 5010 for the X12 transactions and between V5.1 and D.0 for the NCPDP has been completed and is unchanged by the Final Rules. Once the gap analysis and business requirement documentation are complete, Emdeon will share HIPAA Guidance reports with its customers, just as it did for 4010A1 and the NPI, and provide shared roadmaps for implementation.

Commitment and Customer Support
Emdeon’s 5010 Transaction Teams and 5010 Steering Committee are finalizing action plans and deploying resources to address the changes required in the new regulations. Emdeon will work with early implementers to help ensure their needs are met.

Emdeon remains committed to meeting and exceeding the compliance deadlines and supporting its customers and business partners in their implementation efforts through progress updates, educational resources, simplified reporting and consulting services. The company’s overall goal is to be ready to test well in advance of HHS deadlines.

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A Drug Spend Containment Strategy for Medical Pharmacy

2009-02-25T09:36:00.015-06:00

Driving integrated, electronic solutions across the payment life cycle, Emdeon leads the industry with transaction solutions that increase the efficient flow of information among members, providers and employers—and help reduce costs, improve healthcare business processes, and strengthen stakeholder relationships. Through a technology partnership with NovoLogix and the power of its MedRx PrecisionSM application, Emdeon is now delivering enhanced capabilities to immediately impact the estimated $2.1 billion in excess payments currently spent on medical pharmacy claims. Together, Emdeon and NovoLogix are leveraging the latest technology innovations to bring the pricing accuracy and administrative efficiencies that are standard in the pharmacy benefit world to the processing, pricing, payment,and remittance distribution of drug claims paid under the medical benefit.

Consider what MedRX can Deliver
MedRx Precision offers consistent re-pricing and claim edits for injectables, infusables and other pharmaceuticals paid under the medical benefit. Its precise NDC-level data automated drug review applications aids in preventing excessive or inaccurate quantities, streamlining the billing process as a whole. The aggregate NDC-level data across all drugs and services allows for detailed reporting, adds visibility into utilization and dispensing trends data to obtain rebates on all appropriate drugs for claims paid under the medical benefit (consistent with pharmacy benefit rebate strategies). MedRx Precision’s uniform administrative and clinical edits help reduce error rates and can bring even more cost savings to the bottom line. The next generation technology, applications and proven practices, applied to the physician office and home health services, can consistently deliver savings.

Additional Emdeon and NovoLogix MedRX Precision Savings Benefits
With medical benefit pharmacy spend at $36 billion and growing annually, the Emdeon and NovoLogix MedRx Precision collaboration delivers the pricing sophistication and automated efficiencies that health plans, payers, and other partners need to capture drug savings—right from the start.

A one million member plan spends approximately $118 million* per year in Medical Pharmacy (this spend is not managed by the PBM). Industry experts expect this number to increase 10-20% per year due to the growth of the biotech pipeline. Emdeon has partnered with NovoLogix to provide a direct savings solution for this specific area of spending.

This solution can save a one million-member plan up to $7 million per year* without changing contractual rates with its provider network.

Effective January 1, 2008, the Deficit Reduction Act (DRA) mandates that NDCs must be submitted in order to collect rebates for physician office drug claims. MedRx Precision offers a simple and cost effective solution for this mandate.

Interested in more information on this partnership solution? Contact your account manager today or email us at moreinfo@emdeon.com.
*NovoLogix estimates for private health plans based on 2007 IMS data.

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Effective Care Management Programs Succeed in Reducing Medical Costs at Health Plans: An Interview with TRICARE North-Health Net Federal Services

2009-02-25T09:15:00.016-06:00

TRICARE North–Health Net Federal Services recently implemented Emdeon Hosted Health Service Review to help improve care management for consumers and providers. The added efficiencies from automating the historically manual and time-consuming process of receiving and responding to requests for referrals and authorizations are discussed in the following interview with TRICARE North–Health Net Federal Services’ Mark Sconce, EDI marketing representative and Jimmie K. Ramos, senior systems analyst.

What factors influenced TRICARE North-Health Net Federal Services' decision to implement a hosted Health Services Review (278) transaction solution?

[Mark Sconce:] A number of factors played a role, but essentially, we recognized the available savings for both providers and our health plan.

[Jimmie K. Ramos:] Improving information accuracy up front, early in the Referral and Authorization process, was also top priority for us because it impacts the entire downstream process. With paper requests, there are the obvious issues with legibility of individuals’ handwriting and key data that is often missing. The drawbacks associated with paper requests result in numerous callbacks or correspondence with providers in order to collect the necessary information.

You chose to partner with Emdeon for your hosted electronic 278 solution. How did you determine that Emdeon was a good fit?
[Mark Sconce:] We have a large provider population so Emdeon’s network of connected providers made them (Emdeon) a good fit….a one-stop-shop to roll-out the hosted electronic 278 to the largest possible number of providers.

[Jimmie K. Ramos:] Emdeon’s existing relationships with providers were definitely a factor in our decision. Since many providers currently submit claims to Emdeon, it’s a logical step for providers to move to an electronic 278.

From an IT perspective, Emdeon is close to plug and play. Emdeon eliminates providers’ needs to invest in technology solutions to communicate with payers securely; and they enable providers to engage in EDI at low cost, within a short time.

How has TRICARE North-Health Net Federal Services benefited by implementing electronic referrals and authorizations?
[Jimmie K. Ramos:] By migrating the Requests for Referral and Authorization to an electronic transaction, we’re able to offer improved service to our providers. By applying HIPAA EDI standards to the process, data is clearer, more concise and specific– effectively removing a layer of subjectivity. That can have a direct correlation to the quality of care a patient receives.

[Mark Sconce:] Absolutely. Efficiency and processing time have dramatically improved. Before we began accepting the Requests for Referrals and Authorizations electronically, we would receive requests via fax. Those would get processed, printed and sent for keying into the system, all before it even reached the analysts desk who can act upon them. With EDI, data goes directly to the analysts who need to work it. Providers can check the status online without ever picking up the phone.

For us, the turn-around time for processing and responding to hosted electronic requests has decreased dramatically and the entire process has become far more efficient.

To learn more about how Emdeon Hosted Referral and Authorizations can reduce costly, manual processes and simplify your business, contact Jay Ratcliffe, Director, Product Management at 707.527.0499.

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Medicare Secondary Payer- Mandatory Reporting

2009-02-24T15:42:00.022-06:00

Managing the complexities and achieving compliance

What is Section 111?
Section 111 of the Medicare, Medicaid and SCHIP Extension Act of 2007 (MMSEA) requires group health plans (GHP) and liability (including self-insurance), no-fault & Workers’ Compensation insurance to determine Medicare entitlement of their members and report on those active covered individuals to Medicare. The quarterly reporting will help the Department of Health and Human Services (HHS) identify situations where the group health plans or no-fault, liability and Workers’ Compensation and self-insurers, not Medicare, should be the primary payer for participants entitled to Medicare. For plans that do not have an existing VDSA/VDEA with CMS, electronic registration is from 4/1/2009 to 4/30/2009 via the Coordination of Benefits’ (COB) website. Liability (including self-insurance), no-fault & workers’ compensation insurance plan registration begins 5/1/2009 and end 6/30/2009.

In exchange, the Coordination of Benefits Contractor (COBC) will provide payers with the Medicare entitlement information for those individuals in the payer plan that can be identified as Medicare beneficiaries. Detailed information about Section 111 and its implementation can be found on CMS’s website through the links referenced below.

Challenges and the silver lining
Although Medicare-eligible members are only a small portion of payers’ overall membership base, management of these members can require system modification and increased administrative costs in 2009 and 2010. Section 111 reporting presents significant challenges in data collection & exchange, system and coordination of benefits process modifications, reconciling potential conflicting information and responding to anticipated increase in Medicare demand letters. The initial and ongoing effort could consume the time and focus of multiple resources.
However, there is a potential silver lining. Section 111 allows the reporting entity to query the Medicare Eligibility Database to identify Medicare entitled/enrolled members. Consultants report that approximately 700 to 2,000 out of every 100,000 members under the age of 65 are not identified by a health plan.* There are prospective savings due to early and efficient identification of Medicare members who were previously difficult to identify. Increased use of crossover claims make it more cost effective with a focused identification of the primary and secondary payers.

So where can we go from here?
Emdeon is working together with payers to provide a service that quickly and cost effectively enables payers to meet the MSP mandatory reporting obligations. Payers can meet the Section 111 reporting mandates by leveraging Emdeon’s experience in data hosting, electronic data interchange and history of successful partnerships with government and commercial payers. Have questions or are interested in more information on Emdeon’s Section 111 Medicare Secondary Payer Mandatory Reporting service? Email one of our product management experts, Sanju Pratap.

Other useful links:
MMSEA Section 111 Reporting
Mandatory Reporting Registration Resource

*Source: Huron Consulting Group

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Workers' Compensation Simplified by Electronic Transmission of eBills and Claim Attachments

2009-02-24T15:34:00.013-06:00

Applicable law or proposed law in many states, including Texas, California, Minnesota, Iowa, Maine and Georgia requires electronic transmission of Workers’ Compensation bills. While electronic transaction rates are extremely high for other lines of business, Workers Compensation (WC) claims have historically been very difficult to transmit electronically due to the high percentage claims which require claim attachments.

Receiving WC claims and their attachments via paper causes a number of challenges for payers. Lost efficiency due to required manual handling, decreased accuracy from claims paired with incorrect attachments, storage and retrieval, and timely adjudication while waiting on requested documentation are just a few of the “opportunities” in the WC line of business.

Emdeon’s current beta test in Texas of a new capability to transmit electronic claims, or eBills, and their accompanying claim attachments, offers the potential for dramatic improvements to WC administration. By streamlining submission and bill processing for jurisdictional ASC X 12N 837 Workers’ Compensation bills, Emdeon eliminates the barriers that had previously complicated the acceptance of eBill traffic from healthcare claim subscribers, thereby helping deliver clean bills to payers.

With this new solution, Emdeon offers the ability to reduce the amount of manual bill processing that often depletes staff productivity for both healthcare payers and providers. Additionally, Emdeon’s electronic processing solution helps reduce the potential for error.

Emdeon WC eBills & Attachments simplifies provider submission of WC bills to payers by integrating bill attachments into existing provider workflows for submission of electronic (837) claims. The electronic link between the claim and attachment enables WC payers to receive bills electronically, versus on paper, improving efficiency and decreasing administrative costs. Emdeon’s process for eBills follows current provider and payer workflows for sending/receiving any other electronic group health or government claim.

Attachments can be sent by two methods: either uploading an electronic attachment, or printing a bar-coded fax cover sheet. The bill and attachment are processed and linked, then sent to the payer. Providers also receive claim status reports and ERAs for the WC claims.

This new capability represents another example of how Emdeon enhances the value of its industry leading healthcare information network to deliver innovative services to the marketplace. To learn more about Emdeon WC eBills & Attachments, contact your account manager, call us at 877.EMDEON.6 (877.363.3666), or email us at moreinfo@emdeon.com.

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A Place at the National Podium

2008-10-01T17:30:00.003-05:00

Emdeon’s Senior V.P. Miriam Paramore Addressed Delegates, Officials & Notable Guests, Shared in National Dialogue at a DNC Healthcare Reform Forum

Amidst the feverish excitement of the recent Democratic National Convention in Denver, Emdeon Business Services participated in an event—in a national dialogue, really—that soberly transcended party lines or affiliations to address a topic relevant to all Americans: healthcare reform.

The public Health Policy Forum, of which Emdeon was a corporate sponsor for an opening VIP reception, brought together a host of influential figures to discuss the present and future of our nation’s healthcare system. Emdeon’s Senior Vice President of Corporate Strategy, Miriam Paramore, herself a recognized thought leader in the industry, offered opening remarks for the reception, representing Emdeon in welcoming the likes of Congresswoman Allyson Schwartz, author of the E-MEDS Bill which requires e-prescribing for Medicare, columnist Arianna Huffington, and Kansas Governor Kathleen Sebelius.

“Emdeon is in the conversation,” Paramore says, recapping her experience at the event. “I’m thrilled to represent a company that’s doing the right thing...participating in the dialogue on the healthcare crisis that affects us all...to help in real, material way.”

Paramore came away energized not only by Emdeon’s role in the national discussion, but in how the company plays a substantive role in “moving the needle” by digitizing the industry and using information technology to turn raw data into usable information. Effective information exchange is essential to the functioning of the entire healthcare system, especially as that system is in a constant state of evolution.

“Our mission is to simplify the business of healthcare,” Paramore explains. “That’s why we are part of discussions on public policy and regulation, to stay on the forefront and influence direction changes that impact the electronic exchange of healthcare information. We are often the connecting point that keeps our customers prepared and ready. ”

Now more than ever, Emdeon is the “glue for the industry when changes occur that impact health information exchange.” By staying close to the regulatory machination, Emdeon is consistently ahead of the game, investing to accommodate altering governmental and industry standards/requirements long before business partners will be affected.

From pay-for-performance issues to handling unfunded mandates and quality initiatives, Emdeon aggressively seeks ways to use technology to make data accurate, expedient and readily accessible for payers, providers, and pharmacies. By improving eligibility transactions and applying business intelligence to EDI, Emdeon is helping reduce the $150 billion of inefficiencies* related to insurance and billing activities that burden the healthcare system each year.

“Of course, this is our business, and our customers are our priority. Yet as we better serve our customers, we are improving the system as a whole. We’re motivated to step up our corporate responsibility to make a difference. We are not on the sidelines, in the quest for true reforms” Paramore summarizes. “We encourage our business partners to do the same.”

What does all this mean to you? Here are a few key ‘take aways’ Paramore shares with you from her DNC Health Reform Forum experience.

• Join the conversation. What individuals in your organization are committed to knowing issues, defining goals and finding solutions? Whether you begin simply by staying more informed or you choose to participate more prominently, you must be in the mix; your voice is vital to reform.

• Start your own conversation. Create ways to communicate with constituencies within your organization about key issues, to gain perspective from all angles. Start dialogue, and ensure communication is two-way so that questions, ideas and information can be shared effectively.

• You can count on Emdeon to help connect the dots. As you join in discussion and generate conversation from within, you can count on Emdeon to help filter and share information throughout the industry. Connect with your Emdeon account manager- we will always do our best to accurately represent your ideas, questions and concerns to the associations and industry and governmental groups in which we participate.

*Source: Center for Financing, Access and Cost Trends, Agency for Healthcare Research and Quality: Medical Expenditure Panel Survey, 2005; A New Model For Enhancing Care While Reducing Costs, Source: Cap Gemini, E&Y May 2002