InstaMed Blog

On January 1, 2014, all payers will be required to support electronic funds transfer (EFT) and electronic remittance advice (ERA).  When evaluating how to achieve ERA/EFT, one of the first decisions a payer will need to make is to “build or buy” – whether to use internal resources to build ERA/EFT capability or to work with a third-party vendor.

Regardless of which model a payer follows to achieve ERA/EFT, there are several key considerations that need to be included in the project scope from the beginning.

1. Provider Adoption

It’s not enough just to support ERA/EFT.  Payers need to be able to reach their providers easily to enroll them in ERA/EFT quickly to maximize print and mail cost savings.  A comprehensive provider adoption plan includes an analysis of how to best reach providers, messaging to educate providers on the benefits of going electronic, multiple ways to enroll providers and resources to support provider enrollment and training.

2. Financial Controls and Daily Monitoring

Before implementing ERA/EFT, a payer needs to establish dedicated resources to monitor all payment activity on a daily basis (not just business days!).  Additionally, the payer will need to prepare to support financial regulatory requirements and protect against fraud when enrolling providers, as well as to support bank account changes, Know Your Customer (KYC) verifications and other provider inquiries in a timely matter.

3. Compliance Requirements

The January 2014 mandates not only require payers to support ERA/EFT, but there are detailed operating rules, developed by CAQH CORE, with specific requirements that payers need to follow.  To avoid penalties, payers will need to identify resources to understand the operating rules and verify that the payer is compliant.

4. Third-Party Relationships

Even if payers build ERA/EFT capability, unless they own a bank, they will have to gain access to the financial networks to move money electronically.  However, if payers choose to work with a vendor, they need to make sure they know who they are buying from and any downstream, third-party relationships that the vendor may require to deliver a complete solution.  For example, most ERA/EFT vendors have critical third-party relationships for delivering an ERA/EFT solution.  It’s crucial for a payer to understand all of the relationships in scope, including who enters into agreements, who is accountable for monitoring claim payments and reconciling cash flow/balance daily, who is responsible for customer support for providers, etc. This will help to assess points of failure, risks and the continuity of service for dealing with difficult issues that arise in an electronic processing environment.

5. Implementation

Implementing ERA/EFT should be treated as a project requiring detailed planning and analysis across multiple departments.  Before beginning to implement ERA/EFT, payers should put together a full project plan that includes details of project resources and responsibilities, the scope of requirements, a comprehensive testing plan and pilot providers.

 

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