View
4
Download
0
Category
Preview:
Citation preview
16 The Self-Insurer | www.sipconline.net
Organizations are faced with a variety of choices when it comes to
potential electronic payment solutions. Finding the right product
for an organization is more than checking a capabilities list; it also
needs to include evaluating service quality, implementation timelines
and associated integration costs. This report will educate the user on important
considerations when conducting a vendor review.
Electronic Adoption – Is it Really Happening?Indeed, it is. The change is occurring, in part, due to the regulatory development
of global operating rules related to the transmission of electronic funds transfer
(EFT) and Electronic Remittance (ERA). 1 Effective on January 1, 2014, the proposed
new operating rules in development by CORE/CAQH in response to Section
1104 of the Affordable Care Act (ACA) is the driver for the insurance industry to
become compliant. This legislation compels healthcare payers to have the ability to
transmit electronic payments to any provider that requests transmission of payment
and remittance data in this manner. Under the proposed new rules, each health plan
will be required to attest to their compliance with significant penalties as a deterrent.
As these requirements and rules further develop, many health plans will rely
Considerations When Evaluating Vendor Solutions for Electronic Adoption and Compliance
Written by Jennifer Plake and Tom Davis
April 2015 | The Self-Insurer 17
© S
elf-
Insu
rers
’ Pub
lishi
ng C
orp.
All
righ
ts r
eser
ved.
on their payment administrator to
assist with this compliance. As the
payer steps in, many may find they
need help from a third party vendor
who has already achieved CORE
certification. When choosing a vendor
partner, there are several important
factors to consider.
• Do your homework –
Multi vs. Single Source Solutions
• Vulnerabilities and security risks
• Timeline for achieving compliance
Do Your Homework – Multi vs Single Source Solutions
Multi-Source Solutions Some
vendors appear to offer everything
you need. However, when more closely
examined, these vendors specialize in
only one payment resolution method.
As an example, there are many
electronic vendors offering a virtual
card driven solution. EFT capabilities,
which deliver the compliance you
seek, are often limited with insignificant
levels of providers actually enrolled to
be paid in this manner. This creates risk
and may introduce new complications
in your workflow as often time the
burden will fall back upon the payer
to engage and enroll providers or
seek additional vendors to provide the
needed EFT adoption.
These suppliers seem attractive
at first because they offer a lucrative
revenue-sharing option, generated
from the virtual card. However, the
virtual card is only a single piece
of evaluating a sustainable long-
term solution. When conducting
your vendor evaluation, important
considerations should be:
• Do they have online support for
providers to easily sign up for
compliant EFT/ERA and opt-out
of virtual cards?
• Do the various payment options
require a separate and distinct
funding process?
• Can they produce a compliant
EFT/ERA from your data file?
• How many EFT providers do
they have enrolled?
• How do they enroll
EFT/ERA providers?
Payers evaluating these solutions
should also pay close attention to the
implementation plan and payment
reconciliation workflows. Many times
multi-source solutions issue and
settle payments from three separate
sources. Your internal workflow can
become cumbersome and require
additional support to reconcile all of
your payments. Be sure to request a
documented Implementation Plan with
timelines and resource expectations.
You can avoid a failed or stalled
implementation by using a well-defined
implementation plan to set proper
expectations. However, be aware of
indicators that you are implementing
multiple payment processes with a
single vendor. If the vendor issues and
settles payments from different sources
based on payment modality, daily
workflows and processes may become
more complex from your current state.
While quality multi-source
products can produce beneficial
results, expenses can climb if you have
to add two or more multi-source
vendors that each solve a single
need. The payer may feel they need
to reinvent themselves in order to
accommodate each vendor’s separate
methodologies. Be confident that
you do not need to implement a
short-term or incomplete solution. A
multi-source solution usually cannot
manage all of your payments without
complicating your daily operations.
Single Source Solutions Single
Source solution vendors can manage
all of your payments and offer the
payer a steady reconciliation process.
A single source solution will preclude
a payer from interfacing with multiple
vendors, banks or other interfaces of
the payment stream. Effective solutions
should include important features
such as the ability to link the real-time
payment status to the adjudication
system detail and originating funding
event. This simply means that a payer
can locate all relevant details for all
payments through a single data source
including images of cancelled checks.
Additional important distinctions
should focus on a long-term vision
of migrating providers to electronic
payments without exclusive
dependence upon a virtual card. Payers
should ask very specific questions
about the number of providers
enrolled for EFT and for specifics
on their population of Provider Tax
ID’s. If the vendor cannot confirm a
match of 25% or greater, the program
will very likely achieve substandard
results. ERA capabilities should also
be properly vetted in this discussion.
Confirm the vendor’s capabilities to
produce a compliant 835 from your
current extract or print file. Ask specific
questions about their experience
with different adjudication systems,
current production volumes and if any
crosswalk or tables will be required.
Any vendor under consideration
should have well-documented
implementation plans and weekly
accountability calls. Newly
implemented payers will be a very
important reference point to confirm
associated implementation timelines.
The implementation team should have
the ability to manage and lead the
customer through a fully customized
implementation that accounts for
unique customers or plan designs.
18 The Self-Insurer | www.sipconline.net
The result of these efforts is a refined, streamlined daily operation and workflow.
A quality decision under a single source platform should include:
• Market leadership in virtual card and EFT/ERA distribution
• Provider payment preference management
• Compliant EFT/ERA from your existing data file
• Single resource for reconciling all payments – card, check and EFT
• Implementation results that can be verified through client references
Consider Vulnerabilities and Security Risks A critical step in the evaluation process is security. In healthcare payment
processing there are many possible exposures such as private health information
and banking transaction details. In your evaluation, ask how personal health
information is protected and how security breaches and financial loss are avoided.
Established vendors are comfortable providing documented support of their
security infrastructure and software protocols along with backup, failure and
redundancy programs. Further, they can offer a voluntary third party audit of
their organization proving their claims. This level of scrutiny compliance with not
only healthcare regulatory procedures such as HIPAA and ACA, but financial
transactions are protected as well through FDIC insured payments and Payment
Card Industry Data Security Standards (PCI DSS) compliance.
With the aforementioned mandate and operating rules, third party payment
services have quickly become a growth industry with many new entrants. Proper
due diligence should include specific questions about a vendors growth and
scalability. Companies committed for
the long-term should conduct regular
assessments and ensure that growth is
aligned with infrastructure capabilities.
In a world where Fortune
100 companies are subject to
data breaches, it is imperative to
understand what measures a vendor
takes to protect your data. With
user interfaces and provider portals,
there are often many access points
that expose a company to potential
breaches. Vulnerability testing and
regular static scans are indicators that
your vendor is taking the necessary
precautionary measure.
If the vendor uses a series of
vendors themselves to provide
their services, be cautious that all
parties maintain the same level of
security standards. Distinct lines of
responsibility and liability should be
clearly defined in contracts.
April 2015 | The Self-Insurer 19
© S
elf-
Insu
rers
’ Pub
lishi
ng C
orp.
All
righ
ts r
eser
ved.
20 The Self-Insurer | www.sipconline.net
April 2015 | The Self-Insurer 21
© S
elf-
Insu
rers
’ Pub
lishi
ng C
orp.
All
righ
ts r
eser
ved.
Timeline for Achieving Compliance Achieving compliance quickly can be a real possibility. Once the due diligence
process is complete and you have narrowed your vendor selection, you can
verify your selections are CORE certified if you have not already by going to
http://corecertification.caqh.org/CORE_organizations. Each health plan can
begin achieving compliance on day one of production with a CORE Phase III
Certified vendor.
A fully engaged payer and vendor can complete an implementation in 6-7 weeks.
If your due diligence indicates that your vendor selection cannot perform within
these parameters with validated references, this may be an indication
to consider other options.
Electronic payment solutions range in quality and effectiveness. To ensure
your organization partners with a vendor that can deliver the capabilities your
organization needs ask the following questions: Do they provide a single source
solution to handle all of my payments seamlessly? Can they provide documented
support of their security infrastructure and programs? Does their solution allow
my company to achieve compliance quickly? If the answer to each of these
questions is yes, then you have found a quality vendor. ■
Tom Davis is the Executive Vice
President of Business Development
and Jennifer Plake is the Strategic Sales
Associate at ECHO Health, Inc., a
leading provider of electronic healthcare
payment solutions. Serving more than
50,000 ERISA health plans and fully
insured groups, ECHO processes more
than $10 billion in payments annually
to providers and members through
industry-leading payers. Founded
in 1997, ECHO is a privately held
company located in Westlake, Ohio.
Recommended