Healthcare EDI Enrollments: Manual Processes and Delayed Payments

 September 17, 2018

By 2020, U.S. healthcare spending will reach almost 20% of GDP, making it the largest spender on healthcare among any nation globally.

While curbing healthcare spending is a herculean task, the 2017 CAQH Index estimates that shifting from manual to electronic transactions between healthcare providers and healthcare payers could save the industry $9.4 billion annually.

Common payer-provider enrollment transactions, such as Electronic Funds Transfer (EFT), Electronic Remittance Advice (ERA), Electronic Data Interchange for Claims (EDI), Claims Status Inquiry (CSI), and Eligibility Verification (EV), are necessary to help healthcare organizations get paid efficiently for their services and for payers to manage provider data.

In the current state of affairs, much of this data exchange is done manually and on paper. For example, despite having “electronic” in the name, ERAs are performed digitally only half of the time.

For the simplest matters – registering for a plan, updating an address, sending bank information – clinicians and administrative staff go through a cumbersome and often error-prone process. Just to complete one form, staff must:

1. Find and learn the enrollment rules. On average, providers do business with 25 payers. Across the different transaction types (e.g. EFT, ERA), that makes for countless forms to download from payer websites, phone calls to make about the latest procedures, and more.
2. Correctly complete enrollment forms. Enrollment forms are usually two to four pages long, but some are as long as 10 pages. Reports suggest that providers spend an average of 8 minutes, and in some cases up to 30, on each form, but rarely can medical staff complete a form in a single sitting. It can take days or even weeks to gather the information to complete a form. Payer requirements also change frequently. Starting, stopping, and restarting paper forms are common headaches.
3. Manually submit enrollments. The largest payers in the U.S. still require providers to send information by mail or fax; these are cumbersome and costly methods of delivery. Not only do medical staff spend time manually sending papers, packages are often lost or are received in an illegible format, and have to be re-sent. It can often take up to a full year for a medical staff team member to learn the ins-and-outs of dealing with different payers. Additionally, many of these are done by hand; the repetitive and manual nature of enrollments leave plenty of room for human error, even with experienced staff.
4. Check enrollment status. After sending paperwork, providers cannot easily check on the status of their enrollments. Over a period of weeks or even months, staff make numerous inquiry calls to payers, and often they will be told that their submissions were lost or rejected due to error. Meanwhile, providers are treating patients without receiving the correct reimbursements.
5. Go back to square one. About 20% of enrollments are rejected due to errors, so medical staff must start the process of finding, completing, and submitting forms all over again.

The burden from these manually-processed transactions is substantial. Lack of timely enrollment or information updates can lead to denied claims, missed referrals, and delayed payments. Additionally, providers lose 1.1 million labor hours per week – time that could otherwise be spent treating patients – to these processes.

With providers burning out at alarming rates and billions of dollars in savings waiting, the industry cannot afford to let the inefficiencies of manual administrative transactions continue. It’s time to move from paperwork to “digital-work” in healthcare administrative transactions.