Co-authored by Scott
Brener, Vice President and General Counsel of SFM, and Dr. Greg
Krohm, Executive Director of the IAIABC
When it comes to
processing and paying medical bills, workers' compensation is
distinctly different than general health insurance. Some of
these differences are unavoidable, like the need for detailed office
notes and prior medical history to be sent with bills.
However, workers’ compensation can improve its efficiency by
adopting electronic billing and payment systems that parallel the
electronic standards long used in general health insurance.
The efficiencies gained from sending medical claims information in a
uniform, electronic format offers the potential to reduce overhead
costs for providers and payers alike.
Texas
was the first state to mandate e-billing with a prescriptive
approach and sweeping legislation. Allen McDonald, Director of
Information Management Services, Texas Department of Insurance, has
sought to inform stakeholders, explain the requirements, and work
through some of the unforeseen difficulties. Mr. McDonald said,
“We have been working diligently to resolve the initial problems
and through hard work and cooperation the acceptance and use of
e-billing in Texas
is growing.”
California’s
legislation is more permissive, hoping that the economic incentives
will be sufficient to motivate providers to comply with e-billing
requirements. “It remains to be seen whether rewards or demands
will produce the best results. Being too rigid at this early phase
in electronic standards may be costly,” said Michael Reed, Texas
Medical Society.
With
Texas and California paving the way, other states including Oregon
and North Carolina are considering similar requirements. In 2007, Minnesota
enacted a comprehensive e-bill statute that covered workers’
compensation.
One
fear many have about enacting e-billing legislation is that it will
limit an injured worker’s access to care. Small clinics, or larger
ones that treat few injured workers, may have limited incentive to
implement a special e-billing system for workers' compensation.
Moreover, forcing workers’ compensation bills through a
different system than general health insurance may cause doctors to
stop treating occupational injury cases.
The
provider and payer community noted both successes and failures with
implementation of e-billing requirements. “We are delighted with
the improved payment speed and efficiency of e-bills. We encourage
electronic protocols with our client-payers,” commented Greg
Gilbert, Senior Vice President at Concentra. Mr. Gilbert noted that
e-bills result in average payment in 45 days, compared to 65 days
for paper claims.
This
positive experience was shared by Michael Berkowitz, KSF
Orthopaedic
Center
in
Houston, Texas. “Unfortunately, a lot of the bills we submit electronically do
not get to the insurer in a purely electronic format”, reports
Berkowitz. “Too often some intermediary agent will not know what
to do with our bill and just print it and send it by mail.” This
“drop back to paper” phenomenon is a glaring failure in the
current e-bill environment.
Payers
also have many reasons to both like and dislike e-billing. As
indicated by Scott Brener, Vice President and General Counsel of SFM,
the promise of e-billing to help eliminate payer data entry and
realize efficiencies of scale has the potential to be quite
significant. “At SFM
we recognize some of the initial constraints associated with e-bill
early adoption, however, subsequent to some system and standards
maturity, we expect electronic billing will drive efficiency within
our insurance space.”
Vendors,
or e-bill agents, play a critical role in facilitating e-billing
between providers and payers. Technology vendors are directly
responsible for finding the route from their client to the ultimate
recipient of the electronic bill and supporting documents.
The
need for supporting medical attachments, generally physician notes,
is a unique feature of workers' compensation claims. Documentation
is generally required by the payer to properly adjudicate a
workers’ compensation bill. Texas law actually gives the sender
several options, from paper to the advanced “275 format” for
completing electronic billing.
In
the end, there seems to be consensus among the experts on the payer
and provider sides that two problems need to be overcome for
e-billing to be fully realized. Firstly, there must be greater
cooperation among vendors in transferring e-bills to the intended
recipients. Secondly, a solution must be found for moving all
electronic attachments from provider to payer. The IAIABC Provider
to Payer Working Group is addressing these and other issues through
the development of a model law for e-billing in workers'
compensation.
To
learn more about the Provider to Payer Working Group or e-billing
initiatives across the country, sign-up as a user to receive updates
on the IAIABC website at www.iaiabc.org.
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