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Paper, fax and EDI: Where intelligent capture transforms claims processing

Bruce Orcutt, Vice President Product Marketing Management, ABBYY USA
Written by: Bruce Orcutt

Even with today’s prevailing electronic exchange of information between healthcare payers and providers, a big portion of medical claims, such as HCFA/CMS-1500 and UB-04/ CMS-1450, is still issued on paper and fax. Manually entering data from medical claims forms or correcting results of zonal OCR performed by a legacy imaging system is a resource-intensive process. Like all manual operations, it is prone to errors, resulting in incorrect payments or rejected claims. And when a practice grows, claims processing scales only by bringing in more staff, which makes it difficult to consistently meet deadlines and productivity targets. The overarching problem with claims processing is the access and management of information from forms.

Fortunately, the digital transformation of information management has proven to improve efficiencies in three common claims scenarios including paper, fax and EDI processing.

Automating Claims Beyond OCR
The automation of claims may have reached an adolescent stage, but it is far from reaching optimal efficiency. If your organization processes large amounts of data on HCFA 1500 sheets then you are familiar with the use of color dropouts and the need for an automation solution that has optical character recognition (OCR) accuracy. Community Eye Care (CEC) is an organization that struggled with manually processing HCFA 1500 sheets. CEC administers vision benefits for employers’ associations and health plans. Among the 150,000 HCFA 1500 forms it processed every year, 56,000 were paper. Processing the paper forms required four people conducting tedious and error-prone manual input. 

Further complicating the process, dropout forms have a color background with white rectangles serving as character cells and checkmark fields. This is great for recognition, but made verification difficult. Using intelligent capture software, CEC’s team took advantage of an Image Overlay in the verification screen — meaning the form background is shown along with recognized data, making verification easier. CEC increased productivity and employee satisfaction, and eliminated the need to bring on additional staff.

Transforming Data from Faxed Forms
There are still several providers that rely on faxed forms. One example is ADURO, a wellness platform provider. Its wellness plan includes biometric testing that require the manual processing of physician fax forms. Biometric testing measures markers such as body mass index, blood pressure, cholesterol levels and glucose levels. The process begins when employees provide their physicians with a form. Each form is tailored to its client and features a combination of bubbles and handwriting – and when completed by a physician, is faxed to ADURO for processing.

Data from physician fax forms was manually typed into ADURO’s database, but even with staff working 10-hour days, those forms were stacking up causing a backlog of inputting information into its database and affecting employees’ engagement with their programs, access to awards and their wellness coaches.

Intelligent capture not only automated the pulling of data from the forms, but also transformed the workflow: incoming faxes are now routed to a HIPAA compliant online fax service that automatically assigns them to the appropriate customer folder on a server. From there, the physician fax forms are loaded on to workstations, then software recognizes and captures the forms’ data. Within the first three months, ADURO was able to successfully process 5,000 physician fax forms. One person is now able to process three to four times as many documents than before.

Transitioning Faxed Forms to EDI submission
Many providers supplement Medicare Health Plan services and therefore need to comply with CMS rules regarding claims submissions, credentialing and utilization. These providers ensure that the Medicare Health Plan’s beneficiaries get care from within their network of specialists, then process the claims and, oftentimes, pay the claims. For example, Podiatry Plan, a provider of podiatry medicine for Labor-Employer Trust Funds (ERISA), provides routine foot care for Medicare beneficiaries. As part of the Medicare Advantage Plan, the Centers for Medicare and Medicaid Services requires a CMS-1500 form to be submitted for each claim.

However, Podiatry Plan had hundreds of paper CMS-1500 forms arriving via fax every month and needed to transition to EDI within eight weeks. Manually entering data from each into a digital format was not an option –it was critical to automate the capture and conversion of forms. Today, Podiatry Plan processes claims for a very large number of the Medicare Healthcare Plan’s beneficiaries and receives several hundred claims every month using intelligent capture that automates and streamlines the process workflow.

No matter the stage in their digital journey, healthcare and plan providers need to think beyond OCR and capture automation and discover how to action information to boost workflows.