William: I will be surprised if this is a significant problem. That being said, I do not support your suggestion that this problem be laid at the doorstep of payers.
I suspect it is true of most payers that they maintain eligibility on a different platform than claims. In fact, the data is probably on multiple platforms -- one for enrollment style information, another for benefit plan related information, yet another for information about deductible and co-insurance accumulators. That fact notwithstanding, given how much trouble it is to get one translator set up I can't see plans setting up a separate entry point for each transaction. What may occur is that Payors may prefer that transactions from a professional provider (e.g. doctors) go in through a different gateway that transactions from facility providers. This is likely to be true when doing business with a Blue Cross Blue Shield Plan and the member has non-HMO coverage. The reason is historical -- the BCBS Plan probably still is set up with a system for facilities and a system for professionals. However, even there, if you are doing business with a combined Blue Plan and they have been combined for some time, they may have unified their enrollment and eligibility systems. This may also happen with any carrier (Blue or non-Blue) that outsources some processing services. This could occur if the carrier outsources processing of transactions from professional providers. More likely, it could happen if the carrier outsources processing from specialty providers. For example, how many carriers interact directly with pharmacists, as opposed to hiring a PBM to do it? The same is true of behavioral health providers. Many carriers outsource that interaction to another company. Remember that self-funded groups are a wild card. In those cases, it may be the group, not the carrier/TPA that chooses which claims go where. The members may be carrying an ID card that has a logo from a particular carrier/TPA, but the provider may be surprised if they try to send a transaction to that carrier/TPA. That situation is outside the control of the carrier/TPA. It is a good point to document. It is a question that providers and clearinghouses basically need to ask and payers need to try to anticipate and answer. The responsibility cuts both ways -- it can't be laid just at the doorstep of payers. In closing, I offer the following comment as a practical caution. Given the number of claims I have seen providers mess up -- sending them to the wrong address, the wrong carrier, empty envelopes, holding them for months before sending them, etc. and then they go crying to the regulators and legislators and say that the only reason their accounts receivables stink is because of big bad carriers -- I can tell you that if someone suggests that providers don't have to take any responsibility for figuring out where to send things that person will find carriers very unsympathetic. Hope that helps. Ken Fody Independence Blue Cross -----Original Message----- From: William J. Kammerer [mailto:[EMAIL PROTECTED]] Sent: Wednesday, April 03, 2002 12:32 PM To: 'WEDi/SNIP ID & Routing' Subject: How can we treat real time as a secondary issue? If there are payers out there who are "running eligibility on a separate system from their claims," then I don't know how we can treat real time as a "secondary issue." Right at the start, won't these payers demand some way to say eligibility requests go here, and claims go there? Or do these payers maintain a single EDI entry point which can do the culling and separation - passing inbound eligibility request functional groups on to a real-time process, while batching claims for the third-shift? Should this "splitting" be the responsibility of the sender (say, the provider) or the receiver (payer)? If the sender, then he's responsible for getting the interchange to the appropriate "EDI Address" or portal for real-time vs. batch. Otherwise, if we agree the burden should be on the receiver, she has to have one portal and split transactions and route internally. My bias would have been to not put this burden on the sender (provider), as I had pleaded in Re: Batch vs. Real Time transactions (30 January) at http://www.mail-archive.com/routing%40wedi.org/msg00113.html. William J. Kammerer Novannet, LLC. +1 (614) 487-0320 CONFIDENTIALITY NOTICE: This E-Mail is intended only for the use of the individual or entity to which it is addressed and may contain information that is privileged, confidential and exempt from disclosure under applicable law. If you have received this communication in error, please do not distribute and delete the original message. Please notify the sender by E-Mail at the address shown. Thank you for your compliance.
