CASE STUDY #2

3rdParty Payors

Insurance companies are the quintessential third party payer economic model. When HITECH rolled into town it seriously complicated third party payments by mandating the use of ANSI 837X12. HITECH legislation mandated that each payor within the government healthcare system would need to adapt the new standard of accounting. Specifically, claims data like ICD-9, ICD10 and CPT codes. The claims data fields were structured such that a uniform method of measurements and calculations would be easier once Interoperability was required.

However, attempts to standardize claims data failed because there are several versions of ANSI 837. While each version was similar, like Windows 7 and Windows 10, are both PC operating systems, the differences were significant for programmers attempting Interoperability. For the programmer tasked with cross communication, it was closer to merging Microsoft PC operating systems with Apple operating systems.

CHANGE Healthcare, Inc., (CHC) set out to solve the interoperability problem. The problem? Some offices were using EMR’s. Some were transitioning to EMRs and some refused. Some physician offices used embedded software and others used fax machines and some even used the US Postal Service, the old fashion stamp. Worse yet they were not mutually exclusive. Originally CHC sent billers a nicely formatted Excel spread sheet and asked the to fill in their claims data. CHC would then reformat every thing into ANSI 837 and send it to whatever insurance company needed the information. The physician would in turn get paid.

This approach however, proved quite tedious and difficult for the doctors’ office to complete in a timely manner. There were many mistakes and ultimately CHC was asking the physician to do something they just weren’t willing to do. As CHC found out, “Change” is hard to do.

CHC needed to reframe the “ASK” of the physician. Teaching 20,000 physicians that each of their special way of doing things was wrong and they need to conform would be nearly impossible. The new ask? Nothing! CHC asked heir customer to simply give them access to the data where it resides. This was simple and straightforward. CHC would use EMERSONS to collect what we needed and when we needed it.

Physicians and billers alike were very relieved to have this simplified and removed from their list of daily chores. Going out and collecting what we needed when we needed it changed everything.

Before its 2015 acquisition, CHC managed 230,000 physicians’ offices using EMERSONS on 22 different EMRS, processing 4.5 million claims a day.