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How Can Healthcare Providers Overcome The Challenges of X12 EDI Standards?

by Eric

To drive global business processes, today’s companies are adopting automated systems. Additionally, companies also take modern technologies into account for developing new products. In order to attain success, effective and constant collaboration with other organizations has become imperative. Close collaboration assists companies to minimize redundancy, provide comprehensive information to implementers, enhancing interoperability. One of the clear examples of information clarity and interoperability is electronic data interchange.

The common EDI transaction is supported by regulatory standards dictated by the governing bodies. ASC ANSI X12 EDI is a simple and effective consensus-based standard that complies with modern business architecture, promotes a precise use of transaction sets, and aids collaboration.

ASC X12 assists the organization in establishing a financial model that complies with any business and country effectively.

Origin of the ASC X12

ASC is the abbreviation of the Accredited Standards Committee who collaborated with North American organizations using EDI. The commonly used inter-industry transaction standard is supported by millions today, covering diverse industries – healthcare, insurance, retail, banking, automotive, logistics, warehousing, food, production materials, supply chain, & much more.

Not long ago the manual, paper-based transactions were used for submitting claims for providers to insurers. To process and respond to the requests, human interventions were requisite. The ability and agility of humans could only transact limited forms, delaying the work, despite overwhelming the employees.

The degraded productivity was a major concern that allowed the emergence of automated transactions. With the myriad of EDI sets, healthcare industries can have seamless and quick claims, advice, or any transactions in minutes.

The standards, such as the X12, are improved with constant upgrades and maintenance for effective business processes. As a result, the EDI solutions streamlines and facilitates the electronic interchange for effective and visibly accurate business transactions.

Common EDI transactions supported by X12 are purchase order, invoice, payment order & remittance advice, return notification & authorization, sales catalog, inventory inquiry, and advice, etc.

The X12 EDI involves message syntax and standard, messaging protocol, and transports. The EDI message is a hierarchical series of structural elements composed in an envelope to transform and exchange EDI formats.

Several parts of EDI messages can have problems, such as invalid or corrupted message contents. Hence, many companies have to deal with overwhelming errors. Below are some common concerns and challenges with Healthcare Interoperability.

Common Concerns With X12 EDI Transaction Sets

The common issue that healthcare entities face with effective EDI transactions is the lack of requisite EDI experience to successfully break down the X12 file formats. In order to do so, many companies have to extend their budget line to accurately process their EDI transactions.

The technology information partner must have deep knowledge of X12 schemas and standards while keeping the highest level of security for minimal errors and efficiency.

The Department of Health and Human Services issued two rules in 2020 regarding patient access to data and improved sharing of information. Additionally, the adoption of standardized APIs was also called upon.

The need for security and accessibility encouraged healthcare providers to initiate the rules – National Coordinator for Health IT (ONC) and Centers for Medicare and Medicaid Services, complying with these rules became a headache for payers and providers. Additionally,

  • The struggle with the payers and providers was to implement APIs.
  • The lack of prioritization for responding to the claims or transactions not just impacts the preparedness but also, affects the internal priorities.
  • During compliance, data quality is another challenge that companies have to manage.
  • Many healthcare organizations lack data standardization and meeting compliance standards.
  • Limited accessibility to the dictated notes and images and narrative texts.
  • Overwhelming data volume becomes difficult to manage, especially when it is not in a readable or ingestible manner.
  • Potential penalties, administrative and business problems caused by regulatory requirements are difficult to navigate.

B2B communications are essential for business continuity, while managing the technical side is a bit challenging, especially when you are weak on the technical side.

The gap can only be filled with the help of experienced IT consultation services providers with specialized knowledge to manage, test, configure, and troubleshoot the existing issues on EDI.

Overcoming Interoperability Challenge

Associating with a new partner demands requisite steps, such as configuring and testing that may take time. However, other aspects that can be beneficial to associate with a promising healthcare EDI solution provider are –

Scalable Trading Partner Communications

The transaction standard you use, not necessarily your trading partner uses the same. Hence the messages sent and received can differ. The healthcare provider can instill their specialized knowledge to customize the nature of the message that makes management and processing easier. Additionally, this results in quick and seamless onboarding for maximum & continuous productivity.

Automating B2B Messaging

If you survey, you will still find multiple companies following the mundane manual process to communicate or transmit messages. A skilled service provider can help you migrate from manual message handling to automated by integrating a robust system, such as ERP. So, you can reduce the number of errors, send and retrieve messages with agility.

Respond to Multiple Payers

With the help of a managed service provider, you can learn to manage and respond to the transactions received from multiple payers at a time. By learning to automate transactions, you can perform different transactions, such as claim status inquiries, and send eligibility inquiries to verify benefit coverage at the same time.

Lowering Account Receivables

Associating with a managed provider can help care providers to collect copayments during the time of service. The provider can access the patient’s current coinsurance, deductible and benefits information, and other eligibility transactions before any appointment via electronic transactions.

Minimize Administrative Expenses

Reducing paper-based forms, supplies, and postages can overcome the processing expense. Additionally, the care providers can reduce the need for human intervention by automating the interoperability of claims, payments, and layering the authorization to access data and referrals.

Manage Information Much Quickly

The assistance of a skilled and experienced service provider can update your current EDI system to make your data transmission faster. The improved and automated processes can reduce the turnaround times than the manual or legacy processes. This also helps reduce the delays and rigidity of the processes while responding to the inquiry in split seconds.

Detering Submission Errors

The legacy systems, when not upgraded, do not remain accurate. Since new rules and standards are dictated with time, healthcare organizations must adopt them for uninterrupted services. A managed service provider with the latest technology and standards knowledge can check for HIPAA standards compliances within your EDI integrated system. They can overcome the gaps of payer-specific requirements at all levels – clearinghouse and vendor. The comprehensive improvement in the process minimizes the claim rejections and enhances the accuracy of data verification for future claim processing delay elimination.

In a Nutshell –

Adopting modern integration methods, like APIs, opens new doors for efficient EDI interoperability. The integration of API with EDI compliments by making EDI messages rich, specific and clear B2B communications.

Despite the benefits of integrating new technologies in your systems, you need to understand the need for modern architecture to support the advancement. Additionally, to add flexibility and simplicity to your solutions, you need to focus on standardization, for which you can also look for assistance. The skilled and expert healthcare providers can help overcome the challenges related to digital transformation efforts, combining technologies while creating opportunities for automation and self-service.

Author’s Bio:

Alicia works with the editorial team of A3logics, a leading company offering enterprise software development services. Exploring the latest technologies, reading about them, and writing her views have always been her passion. She seeks new opportunities to express her opinions, explore technological advancements, and document the details. You can always find her enjoying books or articles about varied topics or jotting down her ideas in a notebook.

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