The use of third-party associates made it difficult to resolve complaint communications with vendors; standards, communication can help.
A white paper from WEDI aims to sort out best practices for managing payments and settling accounts between vendors and payers when a payer uses a business associate who handles and pays claims on behalf of a payer.
The document, from WEDI’s Advisory and Payments Subgroup, aims to provide guidance to suggest approaches for using electronic standards in the process, rather than resorting to manual processes and complicated communications between multiple entities trying to decide on the payment.
These complications arise when health insurance plans outsource some or all of their claims services to a business associate, such as another health insurance plan or vendor. While the patient pays an amount into the network for the services, the provider often interacts with an entity other than the patient’s health plan. “As a result… the provider receives a payment and remittance notice from an entity to which it did not submit the request and may receive payment in a form other than its listed payment method,” the white paper notes.
The paper, accessible here, discusses the challenges of remittance advice information for these situations. Although it addresses issues related to in-network providers, the challenges may also apply to out-of-network providers.
Best practices include using standards, especially for Electronic Remittance Advice (ERA) and Electronic Funds Transfer (EFT) to be communicated to all entities; transparent communication; and the health plan’s responsibilities for mediating the communication of critical information. While the document discusses the challenges of remittance advice in these situations, the challenges of paying these claims “may be addressed in a future version of the Electronic Payments Guiding Principles document, which will be available at WEDI website.