A Question Made To A Third-Party Payer Regarding A Claim The Case For Electronic Remit Advice (ERA), Secondary Claims and Insurance Posting Made Easy

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The Case For Electronic Remit Advice (ERA), Secondary Claims and Insurance Posting Made Easy

Much has been said and written about the Electronic Remit Advice (ERA) not the least of which has come to us through Medicare. Their web site has a plethora of information and disinformation (meaning less than helpful NOT necessarily erroneous). What has yet to happen is mass adoption of either delivery of ERA files to clinics or electronic posting of ERA files by clinics who do receive them.

It is my understanding that in nearly every case insurers are required by HIPAA to provide ERA files and yet many do not. Individual practitioners don’t seem to know the law and even if they did, have little influence getting insurers to comply. While the more powerful clearinghouse can wield sufficient influence to insist on compliance. To their clients’ detriment very few do.

Many clinics I talk with don’t get the ERA files, in part because they prefer to post the remittance advice by hand. There is a strong perception that errors and/or miss-classifications by insurers can be more easily found and better handled manually. I believe this is mostly incorrect. I say mostly because there are some posting programs that do not handle even the basics well. They provide little or no diagnostic information on what was found in the ERA and what was or was not done about it by the posting program.

Some clinics obtain their ERA files, print them and post the entries by hand. This defeats one of the key functions of the ERA and is beneficial only to the insurer who is saved printing and mailing costs. It further complicates research on denials and errors as the printed EOB contains less information the ERA file.

Fortunately the information provided by Medicare does not attempt to address these issues as they are unique to the software employed by the clinic and the procedures used by individual insurers to pay or reject claims. Often it is the precedent setting policies of Medicare that give license to insurers to over complicate the claim approval process. This has created and continues to foster an error prone submission process. Add in the exchange of many if not most of the claims filed with insurers being handled by disinterested, or in some cases interested by virtue of insurer ownership or the existence of proprietary relationships with third party clearinghouses. The tiniest discrepancy whether related to payment of the claim or not can and often is used to deny or reject a claim.

What about Payer Level Adjustments (PLA)? Everyone has them and they create posting problems at the best of times. Electronic posting should identify and report PLA items but should not attempt to post them. Payers, starting with Medicare, should minimize the use of PLA items.

Some features of a good posting program are listed here for your consideration and to help demonstrate solid business reasons for electronic posting. There are many others.

• Automated posting of remittance transactions

• Accept ERA files from any payer or clearinghouse

• Electronic verification and absolutely ACCURATE balancing

• Identifies errors in the EOB from the payer

• Errors can be corrected before posting, should be an option

• Payments, Adjustments and Allowed amounts are posted

• Deductible posted and YTD deductible updated

• Differentiates between Primary/Secondary/Tertiary payers

• Can be processed interactive or in batch

• Integrated Adjustment Code and Denial Code definitions

• Denials on claims not posted; allows option to resubmit

• Denials when posted will create a zero payment and close out the claim loop. Balance is either written off or becomes patient responsibility.

• Notification of Payer Level Adjustments

• Customizable Payment Codes for the batch that is being processed

• Add Employee ID Code to posting transaction for ease of tracking back

• Detailed Posting Reports

• EOB Report – Print, Store indefinitely, ARCHIVE

• Fully HIPAA compliant.

According to the Medicare website two advantages of ERA over the Standard Printed Remit (SPR) are: “The amount payable for each line and/or claim as well as each adjustment applied to a line or claim can be automatically posted from an ERA, eliminating the time and cost for staff to post this information manually from an SPR. ERAs generally contain more detailed information than SPR.”

The additional information in the ERA files also allow for secondary claims to be filed electronically.

When electronic ERA posting is used in conjunction with EFT the opportunity for fraud in all practicality, disappears.

The Case for Electronic Remit Advice is a strong one with many benefits. It remains puzzling to me why relatively few providers have incorporated the ERA into the process of managing their businesses. This is not a medical service decision and has little if any effect on the quality of care provided. It is a financial business decision. When made in the affirmative it will benefit the business of health care.

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