Healthcare IT News - October 2007 - (Page 44)

44 Healthcare It News October 2007 ■ pAyERS www.HealthcareITNews.com aetna begins conversion to real-time claims By FrEd BazzoLI, Contributing Editor – Aetna Inc. is making plans to offer a real-time claims submission service to healthcare providers that allows for direct transactions with insurers. The service, called Aetna EDI Connect, will enable claims submissions without the need for clearinghouses or third-party intermediaries. With the move, Aetna joins other insurers who are seeking to automate the claims submission process and move closer to interactive real-time data interchange and comHARTFORD, CT munication on claims status. To enable the submission connectivity, Aetna has entered a five-year agreement with Ingenix, an Eden Prairie, Minn. -based healthcare information technology company. Under the contract, Ingenix will provide clearinghouse services as well as next-generation managed EDI services that enable healthcare providers and other bill submitters to transmit data directly to Aetna. The service will work through a free direct-connect Web site available to all sub- mitters whose practice management systems can transmit files conforming to standards for the Health Insurance Portability and Accountability Act of 1996. In addition to enabling the Aetna EDI Connect Web site, Ingenix expanded its agreement to provide Aetna with clearinghouse services for electronic transactions through 2012. As defined under HIPAA, these transactions include professional and institutional claims and encounters; electronic remittance advices; real-time eligibility verifications; claims sta- tus checks; and referral authorizations. These transactions use standards from ASC X12, a standards-setting organization for electronic data interchange. Organizations that want to submit claims through the service will need to comply with requirements in the Aetna EDI Connect Companion Guide, which contains examples of automation scripts and can help users determine if the Web site will handle their claims. n More at HealthcareItnews.com e Connect: aetNa 1007 ● FraUd Continued from page 1 data analytics lead for IBM Center for Business Optimization. “We’re offering the services to a larger number of payers that either don’t have dedicated investigative teams or want to augment what they already have,” he said. Payers can select from two dozen medical specialties, such as pharmacy, anesthesiology and chiropractic claims. With the on-demand service, payers such as Excellus will be able to review data analysis in a matter of days or weeks. IBM provides high-level executive summaries, reports and scorecards and further reporting and analysis. “Many of our payer clients have seen ROI in less than a year,” said Ramsey. Excellus’ unit, which has 12 staff members spread across four cities, is in the process of finalizing submission requirements for the prescription drug data that will be sent to IBM. “the report IBm provides will point us to the pharmacies, members and prescribers who are abusing the system. We’ll be able to streamline processes and make us more efficient in finding the most egregious offenders.” – Flora Allen “The report IBM provides will point us to the pharmacies, members and prescribers who are abusing the system,” Allen said. “We’ll be able to streamline processes and make us more efficient in finding the most egregious offenders.” With $2 trillion currently being spent on healthcare, outright fraud is costing $60 billion, said Louis Saccoccio, executive director of the National Health Care Anti-Fraud Association, or NHCAA. The conservative estimate of 3 percent lost to outright fraud – which doesn’t include waste and abuse – will likely remain the same, but the amount of money lost to fraud will increase significantly as healthcare spending continues to rise exponentially every year, he said. Despite the rise in more sophisticated types of fraud, Saccoccio said a combination of software, public-private partnerships and information sharing through NHCAA will help payers stay on top of the never-ending battle. n More at HealthcareItnews.com e Connect: FraUD 1007 ● e ● Connect: GartNer 1007 http://www.HealthcareITNews.com http://www.HealthcareITNews.com http://www.healthcareitnews.com/story.cms?id=7857 http://www.HealthcareITNews.com http://www.gartner.com/us/healthcareit.com http://www.HealthcareITNews.com http://www.healthcareitnews.com/story.cms?id=7830 http://www.healthcareitnews.com/eConnect.cms?id=7917

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Healthcare IT News - October 2007 Contents Global Harmony Telegrowth New Rules Keeping Tabs What's Free? PHR of Its Own Intelligent Closing Practice Management Paper Tiger

Healthcare IT News - October 2007

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