Healthcare & the ACH Network: Good Business for YOUR Business

47 Pages·2013·1.05 MB·English

Healthcare & the ACH Network: Good
Business for YOUR Business
J. Steven Stone, AAP
PNC Bank

Chuck Floyd, AAP
Viewpointe, LLC

Laura Clary, AAP
Fiserv

Alan R. Dupree, AAP
Federal Reserve Bank of Atlanta

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Disclaimer
This course is intended to provide an overview of important healthcare
payments-related issues that will impact financial institutions and the healthcare
industry in the future. Responsibility for compliance with all legal and regulatory
requirements remains at all times with individual users. This presentation and
the information contained in it are not intended to be used as legal advice.
NACHA, PNC Bank and Viewpointe provides this material “as is” without
warranty of any kind, either express or implied, including, but not limited to, the
implied warranties of merchantability or fitness for a particular purpose. This
document could include technical inaccuracies or typographical errors, and
individual users are responsible for verifying any information contained herein.

The information in this document and discussed in this presentation is the
exclusive property of NACHA, PNC Bank and Viewpointe Clearing, Settlement
& Association Services, LLC. It may not be copied, disclosed, or distributed, in
whole or in part, without the express written permission of NACHA, PNC Bank
or Viewpointe.

© 2012 NACHA — The Electronic Payments Association. All rights reserved.
No part of this material may be used without the prior written permission of NACHA. Insert Logo
Content from sources other than NACHA is used with permission and requires the separate consent of
those sources for use by others. This material is not intended to provide any warranties or legal advice,
and is intended for educational purposes only.
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Agenda
• Why Healthcare? Making the Business Case
• Changes to the NACHA Operating Rules to support the
healthcare Industry
• Next Steps – Implementing Solutions

©© 2 021021 2N NACACHHA A— — T hTeh eE lEelcetcrotrnoinci cP aPyamymenetnst sA sAssoscoicaitaiotino.n A. lAl rlli grihgthst sre rseesrevrevde.d .
NNo op aprat rot fo tfh tihsi sm mataetreiarila ml maya yb eb eu suesde dw iwthitohuotu tth teh ep rpioriro wr rwitrtiettne np epremrmisissisoino no fo Nf NACACHHA.A . Insert Logo
Content fCroomnt esnotu frrcoems ostohuerrc ethsa ont hNeAr CthHaAn iNs AuCseHdA w isit hu speedrm wiisthsi opne ramnids srieoqnu airneds rtheeq usireepsa trhaete consent of
those sosuerpcaersa tfeo rc uosnes ebnyt ootfh tehross. eT hsiosu mrcaetse rfioarl uiss neo bt yi nottehnedresd. Ttoh isp rmovaidteer iaaln iys wnoatr rianntetinedse odr tloe gal advice,
provide any warrantieasn odr ilse ginatle anddveidc ef,o ra nedd uisc aintitoennadle pdu fropro esedsu coantliyo.n al purposes only.
4
Agenda
• Why Healthcare? Making the Business Case
• Changes to the NACHA Operating Rules to support the
healthcare Industry
• Next Steps – Implementing Solutions

©© 2 021021 2N NACACHHA A— — T hTeh eE lEelcetcrotrnoinci cP aPyamymenetnst sA sAssoscoicaitaiotino.n A. lAl rlli grihgthst sre rseesrevrevde.d .
NNo op aprat rot fo tfh tihsi sm mataetreiarila ml maya yb eb eu suesde dw iwthitohuotu tth teh ep rpioriro wr rwitrtiettne np epremrmisissisoino no fo Nf NACACHHA.A . Insert Logo
Content fCroomnt esnotu frrcoems ostohuerrc ethsa ont hNeAr CthHaAn iNs AuCseHdA w isit hu speedrm wiisthsi opne ramnids srieoqnu airneds rtheeq usireepsa trhaete consent of
those sosuerpcaersa tfeo rc uosnes ebnyt ootfh tehross. eT hsiosu mrcaetse rfioarl uiss neo bt yi nottehnedresd. Ttoh isp rmovaidteer iaaln iys wnoatr rianntetinedse odr tloe gal advice,
provide any warrantieasn odr ilse ginatle anddveidc ef,o ra nedd uisc aintitoennadle pdu fropro esedsu coantliyo.n al purposes only.
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Annual health care spending in the U.S. is
estimated to surpass $4.2 trillion in 20185
5.Source: Centers for Medicare & Medicaid Services, Office of the Actuary, National Health Statistics Group
©© 2 021021 2N NACACHHA A— — T hTeh eE lEelcetcrotrnoinci cP aPyamymenetnst sA sAssoscoicaitaiotino.n A. lAl rlli grihgthst sre rseesrevrevde.d .
NNo op aprat rot fo tfh tihsi sm mataetreiarila ml maya yb eb eu suesde dw iwthitohuotu tth teh ep rpioriro wr rwitrtiettne np epremrmisissisoino no fo Nf NACACHHA.A . Insert Logo
Content fCroomnt esnotu frrcoems ostohuerrc ethsa ont hNeAr CthHaAn iNs AuCseHdA w isit hu speedrm wiisthsi opne ramnids srieoqnu airneds rtheeq usireepsa trhaete consent of
those sosuerpcaersa tfeo rc uosnes ebnyt ootfh tehross. eT hsiosu mrcaetse rfioarl uiss neo bt yi nottehnedresd. Ttoh isp rmovaidteer iaaln iys wnoatr rianntetinedse odr tloe gal advice,
provide any warrantieasn odr ilse ginatle anddveidc ef,o ra nedd uisc aintitoennadle pdu fropro esedsu coantliyo.n al purposes only.
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Massive Scale
• 12.9 billion administrative transactions/year1
• 18% of US GDP in 2010; 20% by 20212
• 4 billion claims eligible for reimbursement3
• 400 Million payments (assuming 10 claims/payment)
• More than 800,000 physicians4 and more than 5,800
hospitals (most of which are community hospitals)5
Most Providers have local banking relationships!
1 US Healthcare Efficiency Index (www.ushealthcareindex.com)
2 Kaiser Family Foundation research (http://capsules.kaiserhealthnews.org/index.php/2012/06/report-health-spending-will-climb-to-nearly-one-fifth-of-gdp/)
3 McKinsey estimate
4 http://www.census.gov/compendia/statab/2010/tables/10s0159.pdf
5 http://www.aha.org/aha/resource-center/Statistics-and-Studies/Fast_Facts_Nov_11_2009.pdf
©© 2 021021 2N NACACHHA A— — T hTeh eE lEelcetcrotrnoinci cP aPyamymenetnst sA sAssoscoicaitaiotino.n A. lAl rlli grihgthst sre rseesrevrevde.d .
NNo op aprat rot fo tfh tihsi sm mataetreiarila ml maya yb eb eu suesde dw iwthitohuotu tth teh ep rpioriro wr rwitrtiettne np epremrmisissisoino no fo Nf NACACHHA.A . Insert Logo
Content fCroomnt esnotu frrcoems ostohuerrc ethsa ont hNeAr CthHaAn iNs AuCseHdA w isit hu speedrm wiisthsi opne ramnids srieoqnu airneds rtheeq usireepsa trhaete consent of
those sosuerpcaersa tfeo rc uosnes ebnyt ootfh tehross. eT hsiosu mrcaetse rfioarl uiss neo bt yi nottehnedresd. Ttoh isp rmovaidteer iaaln iys wnoatr rianntetinedse odr tloe gal advice,
provide any warrantieasn odr ilse ginatle anddveidc ef,o ra nedd uisc aintitoennadle pdu fropro esedsu coantliyo.n al purposes only.
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Massive Opportunity
• Electronic payment rate of 10%1 to 31%2 for commercial
payments; Medicare at 65%+ for physicians3
• 30% of dollars spent go to
administrative costs
(approximately $700 billion/yr)4
• Operational inefficiencies
consume $126 B to $315 B
annually5
1 US Healthcare Efficiency Index (www.ushealthcareindex.com)
2 PwC estimate
3 Interviews with Medicare Administrative Contractors, June 2011
4 PNC Bank estimate
5 PwC Health Research Institute
©© 2 021021 2N NACACHHA A— — T hTeh eE lEelcetcrotrnoinci cP aPyamymenetnst sA sAssoscoicaitaiotino.n A. lAl rlli grihgthst sre rseesrevrevde.d .
NNo op aprat rot fo tfh tihsi sm mataetreiarila ml maya yb eb eu suesde dw iwthitohuotu tth teh ep rpioriro wr rwitrtiettne np epremrmisissisoino no fo Nf NACACHHA.A . Insert Logo
Content fCroomnt esnotu frrcoems ostohuerrc ethsa ont hNeAr CthHaAn iNs AuCseHdA w isit hu speedrm wiisthsi opne ramnids srieoqnu airneds rtheeq usireepsa trhaete consent of
those sosuerpcaersa tfeo rc uosnes ebnyt ootfh tehross. eT hsiosu mrcaetse rfioarl uiss neo bt yi nottehnedresd. Ttoh isp rmovaidteer iaaln iys wnoatr rianntetinedse odr tloe gal advice,
provide any warrantieasn odr ilse ginatle anddveidc ef,o ra nedd uisc aintitoennadle pdu fropro esedsu coantliyo.n al purposes only.
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Challenges with Acceptance
^
• Information on EOBs better than 835s
• No re-association needed when dollars and data arrive
together in the mail
• Limited budget for investments in payments technology,
particularly at smaller practices
• Non-standard enrollment terms
• Data collection and maintenance overload (for enrollment)

©© 2 021021 2N NACACHHA A— — T hTeh eE lEelcetcrotrnoinci cP aPyamymenetnst sA sAssoscoicaitaiotino.n A. lAl rlli grihgthst sre rseesrevrevde.d .
NNo op aprat rot fo tfh tihsi sm mataetreiarila ml maya yb eb eu suesde dw iwthitohuotu tth teh ep rpioriro wr rwitrtiettne np epremrmisissisoino no fo Nf NACACHHA.A . Insert Logo
Content fCroomnt esnotu frrcoems ostohuerrc ethsa ont hNeAr CthHaAn iNs AuCseHdA w isit hu speedrm wiisthsi opne ramnids srieoqnu airneds rtheeq usireepsa trhaete consent of
those sosuerpcaersa tfeo rc uosnes ebnyt ootfh tehross. eT hsiosu mrcaetse rfioarl uiss neo bt yi nottehnedresd. Ttoh isp rmovaidteer iaaln iys wnoatr rianntetinedse odr tloe gal advice,
provide any warrantieasn odr ilse ginatle anddveidc ef,o ra nedd uisc aintitoennadle pdu fropro esedsu coantliyo.n al purposes only.
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Electronic Payments Mandate
• Created by the Patient Protection and
Affordable Care Act (PPACA) in 2010
• Requires electronic payments by
Medicare beginning January 1, 2014
• Subject to the operating rules developed by a not-for-
profit entity named by the Secretary of HHS
• CAQH CORE is the entity responsible for operating rules
• NACHA is the standards organization for mandated electronic
payments

©© 2 021021 2N NACACHHA A— — T hTeh eE lEelcetcrotrnoinci cP aPyamymenetnst sA sAssoscoicaitaiotino.n A. lAl rlli grihgthst sre rseesrevrevde.d .
NNo op aprat rot fo tfh tihsi sm mataetreiarila ml maya yb eb eu suesde dw iwthitohuotu tth teh ep rpioriro wr rwitrtiettne np epremrmisissisoino no fo Nf NACACHHA.A . Insert Logo
Content fCroomnt esnotu frrcoems ostohuerrc ethsa ont hNeAr CthHaAn iNs AuCseHdA w isit hu speedrm wiisthsi opne ramnids srieoqnu airneds rtheeq usireepsa trhaete consent of
those sosuerpcaersa tfeo rc uosnes ebnyt ootfh tehross. eT hsiosu mrcaetse rfioarl uiss neo bt yi nottehnedresd. Ttoh isp rmovaidteer iaaln iys wnoatr rianntetinedse odr tloe gal advice,
provide any warrantieasn odr ilse ginatle anddveidc ef,o ra nedd uisc aintitoennadle pdu fropro esedsu coantliyo.n al purposes only.
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Healthcare EFT Standard – Final Rule
• January 10, 2012, HHS issued “Administrative
Simplification: Adoption of Standards for Health Care
Electronic Funds Transfer (EFT)”
– Became final on July 10, 2012 (50 comments; no changes)
– Defined “Health Care EFT” as a transaction under HIPAA for
the first time (45 CFR 162.1601)
– Identified NACHA CCD+ as the EFT standard (45 CFR
162.1602)
©© 2 021021 2N NACACHHA A— — T hTeh eE lEelcetcrotrnoinci cP aPyamymenetnst sA sAssoscoicaitaiotino.n A. lAl rlli grihgthst sre rseesrevrevde.d .
NNo op aprat rot fo tfh tihsi sm mataetreiarila ml maya yb eb eu suesde dw iwthitohuotu tth teh ep rpioriro wr rwitrtiettne np epremrmisissisoino no fo Nf NACACHHA.A . Insert Logo
Content fCroomnt esnotu frrcoems ostohuerrc ethsa ont hNeAr CthHaAn iNs AuCseHdA w isit hu speedrm wiisthsi opne ramnids srieoqnu airneds rtheeq usireepsa trhaete consent of
those sosuerpcaersa tfeo rc uosnes ebnyt ootfh tehross. eT hsiosu mrcaetse rfioarl uiss neo bt yi nottehnedresd. Ttoh isp rmovaidteer iaaln iys wnoatr rianntetinedse odr tloe gal advice,
provide any warrantieasn odr ilse ginatle anddveidc ef,o ra nedd uisc aintitoennadle pdu fropro esedsu coantliyo.n al purposes only.