EFT and ERA Design Outline
I. Introduction
A. The organization is called a third part administrator (TPA). The company handles Major medical, supplemental, indemnity, and hospital /surgery policies. The process encompasses banking, customer service, claims processing, medical review, medical case management, and releasing payment.
B. Process is to set up guidelines for Electronic payment submission and remittance submission
C. Literature highlights
D. Discuss Internal and External stakeholders - Physicians, venders, employees etc.
II. Affordable Care Act and Information Management Standards
A. Monitoring Delinquency and interest rates.
B. Monitoring Confidentiality of Information - This is monitoring of access to protected health information
C. State and federal prompt pay rules and mandates
D. Communication guidelines
III. Describe how these standards are used in our facility
A. Describe how each claim and payment will accurate and complete.
B. Describe how Physicians and insured will be notified of delinquent payments.
C. Draft corresponding letters for EFT setup and ERA remittance.
D. Procedure for non-completed or rejected claims.
E. Review Release of Information (ROI) status
F. Challenges discussed on anti-kickback regulations
G. Employees knowledgeable in HIPAA requirements and yearly certification and what this entails.
IV. Design and Develop action plans
A. Team meetings - Importance of management and company implementing code of conduct and believing the companies Mission Statement.
B. Setting up action plans, SWOT analysis
C. Implement processing guidelines
- Claims processing area
- Tech support - programing, software
- Finance - bank feed and client feed
- Service - W-9 uploading provider information
- Mailroom- scanning , check and remittance printing and mailing
D. Budget management- project manager estimate cost- cost fluctuates
E. Training- processing and call center talking points
VI Conclusion
A. Evaluate project outcome
B. Project change over
VII Bibliography