Throw Back Thursday Topic: 2014 EFT and ERA Mandates

Almost one year ago on 10/8/2013, I published an article titled “Did You Know about the ACA EFT and ERA Mandates”.  When I found myself surprised at some of the payer rules going into effect on January 1, 2014, I was compelled to share that news.

The policies I was most pleased to hear about were the requirements of payers to be compliant in offering electronic funds transfer (EFT) andgovernment ACA mandates electronic remittance advice (ERA) and adopting set operating rules and technical standards for those transactions.

January 1 came and went and I did see many of my contacts in the billing world have access to many more ERAs and EFT reimbursements.  

It was disappointing though that many of the smaller commercial payers were unwilling to communicate their ERA data with automated clearinghouses.  Instead they require providers who want their ERAs to access them from their own payer portal. 

There really isn’t much advantage that I can see in that for providers.  These ERAs usually cannot be imported into the medical billing software for auto-adjudication, so staff is forced to still waste time with manual payment entry.

Another rule I often saw ignored was that of the standardization of the explanation of benefits.  Admittedly it was mostly on paper EOBs produced by small payers that had ignored the whole “have to offer ERA” rule anyway.  Maybe there is some loophole about payer size that provides exemptions to these policies.

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When I saw a recent article titled “Physicians Losing Money by Not Utilizing Electronic Transactions” published by Medscape Multispecialty online magazine I had to check it out.  It provided some very interesting report data from the Coalition for Affordable Quality Healthcare (CAQH) about physicians and electronic transactions.

As a side note, I CAQH.  By creating a site where providers can keep all necessary credentialing documentation that can be accessed by participating payers is a gift to all physician office administrators!

electronic funds transferThe financial implications noted in the article were so astounding; I wanted to hit on some of the numbers that really demonstrate the influence of those electronic transactions.

Electronic Transaction Stats from 2012

Claims status inquiries: 57%         EFTs: 60%            ERAs: 50%

Claims submissions: 91%               Eligibility and benefits verifications: 68%

Prior authorizations and referral certifications: 15% (110 million of the 130 million were done manually)

The researchers gave estimates of the staggering amount of money that providers are costing themselves by not fully utilizing all available electronic transactions:

$3.5 billion from electronic eligibility verification

$1.5 billion from electronic prior authorization transactions

$1.7 billion electronic claim submission, claim payment, claim inquiry, and remittance advices

Higher costs per manual transactions:

Claims submission: $1.56 more

EFT:  $1.53 more               ERA: $1.53 more

Electronic eligibility and benefit verification $3.39 more

Claim status inquiries: $2.02 more            Prior authorizations: $13.33 more


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