Claims management is a multi-step process that provides ample opportunity for errors and delays, but if payers modify their approach to certain steps in the process it could have a positive impact overall.
In the most concise language, claims management starts with a provider sending a claim or prior authorization request to a payer. The payer either indicates that this claim is not covered under the patient’s plan (a denial) or responds by reimbursing the claim.
Within that deceptively simple concept, however, the payer and provider perform a communication dance which includes an acknowledgment that the claim has been received, benefits coordination on behalf of the patient, a claims status inquiry, remittance advice, and other touchpoints.
Traditionally, communication occurred through manual processes. Inquiries and evidence might be passed back and forth by mail or fax.
However, healthcare experts such as April Todd, senior vice president of the Committee on Operating Rules for Information Exchange (CORE) and explorations at the Council for Affordable Quality Healthcare (CAQH), have been urging the industry to leverage electronic methods for carrying out claims management.
“There has been a lot of good progress just around electronic transactions,” Todd told HealthPayerIntelligence. “Generally speaking, we have been lagging in areas that require a clinical connection and that’s related to attachments and prior authorizations. In other areas, we’ve seen a lot of gradual continued improvement in this space.”
There are a couple of areas in which the healthcare industry could improve its adoption of electronic claim data transfers and communication. Often, conversations about claims management pitfalls spotlight providers’ role in embracing electronic adoption. However, certain steps in the process can benefit from increased payer electronic adoption.
In particular, Todd emphasized that boosting electronic adoption of attachments is a key focus for CAQH in 2021 along with providing standardized guidance for this process. Payers have a role to play in that strategy, she said.
IMPLEMENTING ELECTRONIC ADOPTION
When a health plan needs further justification to cover a medical claim, the payer will reach out to the patient’s provider and request evidence. The provider may respond by sending back an image, a scan, a lab result, or any other form of documentation necessary.
“Attachments refer to clinical documentation that can support a prior authorization but also the payment of a claim,” Todd explained.
One major challenge in supplying attachments is that the process tends to be a manual one. Providers most commonly submit their claims and prior authorization attachments by mail or by fax, according to the 2020 CAQH Index report.
When the provider sends the requested information manually, they have no way to tie it to the appropriate claim. This forces payers to spend time piecing together the attachments and the claims and those delays can contribute towards poor outcomes for patients.
Only 22 percent of medical health plans were receiving attachments in a fully electronic manner in 2020. This was an improvement compared to 2019 when the share of health plans receiving attachments electronically was two percentage points lower. Nevertheless, almost eight in ten medical health plans still relied on fully manual processes to handle attachments in 2020.
Overall attachment volume decreased by 28 percent that year and represented less than one percent of all medical transactions.
“Oftentimes, claims payment processes can be delayed because there is a need for that clinical documentation to justify the payment of a claim,” explained Todd. “We are working on operating roles at CORE to help streamline that process for attachments and make it more electronic.”
As noted in the CAQH Index report, health plans may use a variety of electronic platforms to exchange claims attachments, including but not limited to ASC X12N 275 and HL7 CDA.
Switching to electronic adoption of attachments has benefits beyond streamlining and speeding up the claims management process for payers and providers. It can also produce cost savings.
In 2020, healthcare payers spent $590 million—or 28 percent—less on attachments overall than they did in 2019, according to the CAQH Index report. However, the costs of manual adoption increased.
The report estimated that a complete industrywide shift from manual attachments to fully electronic attachments could save the industry $377 million each year, in addition to the $147 million that healthcare payers already save through electronic attachments.
Payers are already pursuing automated and electronic options in other areas of the claims management process to minimize administrative burdens. Although attachments only represent a small share of medical transactions, reducing time and spending in this area could have a positive influence in shifting the industry towards electronic operations.
NAVIGATING REGULATORY AMBIGUITY
Electronic adoption is not the only issue holding the industry back from streamlining the attachments process. Regulatory ambiguity is another hurdle.
HHS announced plans to propose a rule for standardizing attachments in the spring of 2020, but it had not yet released a notice of proposed rulemaking in the spring of 2021.
“What has made it challenging for us to work in this space is that standards for attachments have not yet been established from CMS or from HHS. It is the one transaction under HIPAA that does not have a standard that’s mentioned,” Todd explained. “The industry has asked us to work on this even without a standard because there is such a desire to address this issue.”
Since there are no standards for attachments as established by CMS or HHS, the task has fallen to CAQH to outfit the industry with a set of guidelines for this part of the claims management process.
The organization will develop standards for both prior authorization attachments and for claims attachments, starting with the prior authorization attachments.
To handle prior authorization attachments standards, Todd said that CAQH has compiled a workgroup that pulls from industry experts. Drawing on their experience, the workgroup will create a set of rules that can provide more structure and certainty around how attachment transactions should work.
The rules will address common hurdles such as how to connect the attachment to the appropriate claim, with the goal of streamlining the process.
Once the workgroup completes its guidelines, it will submit these to the CAQH board. The board can then vote to approve or deny those recommendations.
Once the board approves, the standards can go through a CMS process to be considered for admission into HIPAA regulations.
“We are starting to address this and we are hopeful that that CMS will come out with some proposals that we can connect those with this year,” Todd shared.
According to CAQH CORE town hall records from early 2021, the draft for these guidelines included that the system that health plans choose for attachment exchange must be available 86 percent of the calendar week at a minimum, and health plans have to publish the downtimes.
The draft also indicated that the electronic system should provide a receipt confirmation and outlined the allowable response times. It suggested a minimum amount of data or document size for the attachment and a common format for the workflow.
As the guidelines for prior authorization attachments become more solidified, another CAQH workgroup will start piecing together rules for claims attachments.
According to CAQH CORE’s town hall, the nonprofit anticipated that the prior authorization attachments rule development process would extend through the third quarter of 2021 with the board’s vote in the fourth quarter.
The claim attachments rule development process will start in the second quarter of 2021 and the vote will occur in the fourth quarter as well.
As the industry awaits these rules, Todd recommended that payers participate in the process with CAQH.
“I would encourage people to get engaged in the work that we are doing. It’s a great way to share your perspective and also keep up to date,” Todd said.
“We also try to do our best to do education with the industry as well. I’m doing a number of town halls and webinars working with our other partners within the industry. It’s about getting engaged in that standard process so that we can all work towards having common expectations as opposed to having one-off different technologies all over the place that are hard to adapt.”