The majority of our healthcare clients and contacts still submit claims attachments manually. One of the difficulties is the establishment of a nationwide standard for this process. This article discusses the work going on with various healthcare organizations to set up this standard.
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 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.
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.
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.
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.
The CAQH Index 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.
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.
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.
We are encouraged by CAQH’s efforts and hope that CMS and HHS are quick to review their recommendations. The sooner an electronic claims attachment standard is developed and adopted the better for providers, payers and patients.