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Healthcare reform is a major factor driving change in payer-to-provider payments, including the medical loss ratio (MLR) requirement in PPACA. To reduce administrative costs and meet the MLR mandate, payers are implementing more efficient payment delivery methods. One such method is the offering of ERA/EFT, which combines both the payment and the healthcare payment information to enable provider funding, posting and reconciliation. While many payers have been sending providers ERAs (electronic remittance advice) for years, it’s time for payers to integrate EFT (electronic funds transfer) with the ERAs.

How can payers deliver ERA/EFT to achieve cost savings and meet reform mandates? The first step is understanding and applying the requirements, outlined below:

1. Consolidating Funding, Payments and Processes

Funding Sources: Pull funds from multiple funding sources (employer, multiple groups, etc.) and utilize multiple funding mechanisms

Payment Consolidation: Combine payments across products, employer groups, etc., to avoid sending multiple payments to the same provider

Leveraging a Single Process: Use a single process for print and electronic delivery

2. Delivery of ERA/EFT

Re-association of Payment with Remittance: Trace numbers, addenda records, dates and amounts should match between the ERA and EFT, and should be consistent with the Draft CAQH CORE EFT and ERA Operating Rules

Delivery Options: Offer multiple ERA delivery options, via clearinghouses, direct download or an online portal, and offer multiple EFT delivery options

3. Security & Compliance

Fraud and Data Breach Prevention: Ensure audit controls are in place to track all money and secure provider bank accounts

Healthcare Payment Compliance: Maintain compliance with HIPAA, PCI, CAQH CORE Operating Rules, ACH CCD+ and EFT standards, EHNAC standards, SOC 1 reports and SSAE 16 standards, and NACHA guidelines

Other Industry Standards: Meet standards for 5010 ASC X12, ICD-10, NCPDP, W3C and Oasis

4. Provider Adoption of ERA/EFT

Ongoing Promotion: Increase adoption of ERA/EFT through ongoing promotional campaigns, such as information accompanying every paper check/EOP

Education: Emphasize the benefits of automated reconciliation and re-association, and that ERA/EFT means deposits only (no fund withdrawals)

Simple Registration: Offer easy registration with multiple options and offer multiple ways for providers to access claim and payment information (via an online portal, existing clearinghouse or direct download)

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