1 division of workers’ compensation workers’ compensation information system
TRANSCRIPT
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Division of Workers’ Compensation
Workers’ Compensation Information System
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California L.C. §138.6 California L.C. §138.6 Workers' Compensation Information SystemWorkers' Compensation Information System
• The data collected electronically shall The data collected electronically shall be compatible with the Electronic Data be compatible with the Electronic Data Interchange System of the International Interchange System of the International Association of Industrial Accident Association of Industrial Accident Boards and Commissions Boards and Commissions
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WWW.IAIABC.ORG
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Chapter 4.5 Division of Workers' Compensation
Subchapter 1 Administrative Director-Administrative Rules
Article 1.1 Workers’ Compensation Information System
9702. Electronic Data Reporting (a) Each claims administrator shall transmit data elements, by electronic data interchange in the manner set forth in the…. California EDI Implementation Guide for Medical Bill Payment Records
California Code of RegulationsCalifornia Code of Regulations
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Workers’ Compensation Workers’ Compensation Information System (WCIS)Information System (WCIS)
California EDI Implementation California EDI Implementation GuideGuidefor for
Medical Bill Payment RecordsMedical Bill Payment RecordsVersion 1.0Version 1.0
December 2005December 2005
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L.C. §138.6L.C. §138.6 Goals for WCIS Medical Data Goals for WCIS Medical Data
• Assist the department to manage the workers' compensation Assist the department to manage the workers' compensation system in an system in an effective and efficienteffective and efficient manner manner..
• Facilitate the evaluation of the Facilitate the evaluation of the efficiency and effectivenessefficiency and effectiveness of of the benefit delivery system.the benefit delivery system.
• Assist in Assist in measuring how adequatelymeasuring how adequately the system indemnifies the system indemnifies injured workers and their dependents injured workers and their dependents
• Provide statistical dataProvide statistical data for research for research into specific aspects of the into specific aspects of the workers' compensation program.workers' compensation program.
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WCIS WCIS Electronic Data CollectionElectronic Data Collection
• First Reports of Injury – March, 2000First Reports of Injury – March, 2000
• Subsequent Reports of Injury – July, 2000Subsequent Reports of Injury – July, 2000
• Medical/Bill Payment Reports – March, 2006Medical/Bill Payment Reports – March, 2006
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Medical Data CollectionMedical Data Collection
Injured Worker
Medical Providers
Electronic Data Interface
Insurance Carriers
Electronic DataInterface
DWCWCIS
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Enrollment
Pre-Certification &Adjudication
Claims Acceptanceand
ReportingRequirements
Claims Adjudication
Accounts Payable
EligibilityVerification
Pre-Authorizationand Referrals
Service BillingClaim Submission
Claims Status Inquiries
AccountsReceivable (AR)
Functions
Providers
Functions
Payers
Maintain aBona fide
database of detailed
medical bill payment records
which corresponds
to the FROI, SROI,
UEF,DEU, and WCAB
In California
Function
Jurisdictions
270 (Eligibility Inquiry)
271 (Eligibility Information)
837 (Claims Submission)
835 (HealthCare Claim Payment Advice)
837 Health Care Claim.
997 Functional Acknowledgement.
824 Detailed Acknowledgement
275 (Claims Attachment)*
276 (Claim Status Inquiry)
277 (Claim Status Response)
278 (Referral Authorization and Certification)
148 (First Report of Injury)*
The Nationally Accepted EDI Medical Data System
E-BillingRegulations
WCISRegulations
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What is EDI?What is EDI?
• EElectronic lectronic DData ata IInterchangenterchange
• Standardized electronic exchange of files/data Standardized electronic exchange of files/data between computers between computers
• Standard Set of CodesStandard Set of Codes
• Standard Set of Data ElementsStandard Set of Data Elements
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Standard Electronic File FormatsStandard Electronic File Formats American National Standards Institute (ANSIAmerican National Standards Institute (ANSI))
• ANSIANSI – 837 Health Care Claim – 837 Health Care Claim
• ANSIANSI – 997 Functional Acknowledgment – 997 Functional Acknowledgment
• ANSIANSI – 824 Detailed Acknowledgment – 824 Detailed Acknowledgment
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Standard Non-Medical Code SetsStandard Non-Medical Code Sets• Place of Service Bill/Line CodesPlace of Service Bill/Line Codes
– IAIABCIAIABC
• Revenue Billed/Paid CodesRevenue Billed/Paid Codes– IAIABCIAIABC
• Claim Adjustment Group CodesClaim Adjustment Group Codes– IAIABCIAIABC
• Claim Adjustment Reason CodesClaim Adjustment Reason Codes– IAIABCIAIABC
• California Medical License NumbersCalifornia Medical License Numbers– California Department of Consumer AffairsCalifornia Department of Consumer Affairs
• California Medical Facility License NumbersCalifornia Medical Facility License Numbers– California Department of Health ServicesCalifornia Department of Health Services
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Standard Medical Code SetsStandard Medical Code Sets• HCPCSHCPCS
– Centers for Medicare & Medicaid ServicesCenters for Medicare & Medicaid Services
• ICD_9ICD_9– Centers for Medicare & Medicaid ServicesCenters for Medicare & Medicaid Services
• CPTCPT– American Medical AssociationAmerican Medical Association
• NDCNDC– First databankFirst databank
• DRGDRG– US Government printing OfficeUS Government printing Office
• Medical Provider CodesMedical Provider Codes– American Medical AssociationAmerican Medical Association
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Standard Paper Medical Bill TypesStandard Paper Medical Bill Types
• UB92/HCFA1450 UB92/HCFA1450
• CMS-1500 Form (formerly HCFA1500)CMS-1500 Form (formerly HCFA1500)
• American Dental AssociationAmerican Dental Association
• Universal Pharmacy FormUniversal Pharmacy Form
Standard Medical Data ElementsStandard Medical Data Elements
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Other Medical Data Other Medical Data SourcesSources
• InsurersInsurers
• Payers Payers
• Jurisdictional Licensing BoardsJurisdictional Licensing Boards
• Senders Senders
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Part II Part II WHY EDI?WHY EDI?
• Opportunity to modernize the sectorOpportunity to modernize the sector
• Opportunity to lower per unit costsOpportunity to lower per unit costs
• Opportunity to lower total medical delivery costsOpportunity to lower total medical delivery costs
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• The Challenge:The Challenge:
• Over $5.3 billion in medical costs 2002 Over $5.3 billion in medical costs 2002
• Estimated 15% goes to administration Estimated 15% goes to administration
• Lack of e-commerceLack of e-commerce
• The Opportunity:The Opportunity:
• Retool tired processesRetool tired processes
• Chance to Reengineer processesChance to Reengineer processes
Become fitter, leaner, and ready to Become fitter, leaner, and ready to meet future challengesmeet future challenges
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• Reduced Accounts Payable/Reporting CycleReduced Accounts Payable/Reporting Cycle
• Improved Accuracy (5% data entry errors)Improved Accuracy (5% data entry errors)
• Lower Cost TransactionsLower Cost Transactions
• Reduce/Eliminate paperworkReduce/Eliminate paperwork
• Reduce Operational Costs (office supplies, Reduce Operational Costs (office supplies, postal costs, and telephone charges)postal costs, and telephone charges)
Lowering Per Unit CostsLowering Per Unit Costs
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1993 WEDI Report - Net Savings Potential ($ Billions)Year 1 Year 2 Year 3 Year 4 Year 5 Year 6 Total
Savings $1.9 $3.9 $7.8 $12.7 $16.6 $17.5 $60.4Costs $1.5 $3.6 $5.1 $4.0 $2.5 $1.4 $18.1Net Savings $0.4 $0.3 $2.7 $8.7 $14.1 $16.1 $42.3
1993 WEDI Report - Net Savings Potential ($ Billions)
$0.0$2.0
$4.0$6.0
$8.0$10.0$12.0
$14.0$16.0
$18.0$20.0
Year 1 Year 2 Year 3 Year 4 Year 5 Year 6
Savings
Costs
Workgroup for Electronic Data Workgroup for Electronic Data Interchange (WEDI)Interchange (WEDI)
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Part III Part III Nuts & BoltsNuts & Bolts
• Understanding the Transactions CycleUnderstanding the Transactions Cycle
• Trading Partner AgreementTrading Partner Agreement
• Adopted ANSI StructureAdopted ANSI Structure
• Technical AssistanceTechnical Assistance
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Transaction CycleTransaction Cycle
837 Health Care
Transmission Set
824 & 997Acknowledgments
Trading Partners
DWCWCIS
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Trading Partner AgreementsTrading Partner AgreementsDefine exactly how to exchange transactionsDefine exactly how to exchange transactions
– Communication methodsCommunication methods
– Submitter/Receiver IDsSubmitter/Receiver IDs
– DelimitersDelimiters
– FrequencyFrequency
– Turnaround ExpectationsTurnaround Expectations
– Transactions to be exchangedTransactions to be exchanged
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ClaimClaim
Dr Smith
Dr Smith
Professional Claims
Professional ClaimsProfessional Claims
Professional ClaimsFacilityFacility
Dr Smith
Dr SmithProvide
r
Provider
ClaimClaim
Patient
Patient
ClaimClaimClaimClaim
Patient
Patient Patie
nt
Patient
BillBillLine 1Line 2Line 3
Line 1Line 2Line 3
Line 1Line 2Line 3
Procedureor
a product
837 Health Care Claim Transmission
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ISA*00* *00* **ZZ*003000 *ZZ*WHY INC*020524*1718*U*00401*000000001*0*T:~GS*HC*0003000*WHY INC*20030114*1615*1*X*004010X098~ST*837*0001~BHT*0019*00*0001*2003014*1645*CH~REF*87*004010X098~MN1*41*2*MARY SMITH CLEARINGHOUSE*****46*0003000~PER*IC*MARY SMITH*TE*9135551234*FX*6123334567*ED*6125559876~NM!*40*2*MEDICARE PART B*****46* WHY INC~HL*1*20*1~MNI*85*2*EYEBALL SURGERY ASSOCIATES*****24*123456789~N3*PO BOX 1234~N$*SALISBURY*MO*660453565*US~REF*1C*09876~PER*1C*BILLING PROVIDER CONTACT OFFICE NURSE*TE*9135551234*FX*6123334567TE* 6125559876~HL*2*1*22*0~HL *SBR*P*18**MEDICARE PART B*****MB~NM!*IL*1*BENNING*CARRIE****MI*134-56-7890A~N3*PO BOX 123~N4*NEOMA*MO*67799*US~DMB*D8*19330324*M~MN1*PR*2*MEDICARE PART B*****PI*00065~N3*1000 MAIN ST~N$*ST LOUIS*MO*66666*US~CLM*MEDBGOOD-MIS1*1500***11::1*Y*C*Y*Y*B******P~RE*X4*32D1234567~NTE*ADD*CLAIM NOTE TEXT~HI*BK:3999~NM1*DN*1*FOLLARD*BEN*J**M.D.*24-111223333~PRV*RF*ZZ*101Y00000N~RED*1C*B11277NM!*82*1*TREPED*HOWARD****24*88899-1111~PRV*PE*ZZ*101Y00000N~RED*1C*2327870~LX*1SV1*HC:99213*15000*UN*1*11**1:::**N~DTP*472*DB*81298399~RE*X4*32D1234567~SE*36*0001~GE*1*1~IEA*1*000000001~
What Your Computer Sees
During an 837 Transaction
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Part IV Part IV Implications for PayersImplications for Payers
• Identify points of change\impactIdentify points of change\impact
• Develop internal systemsDevelop internal systems
• Out sourcing to a venderOut sourcing to a vender
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Points of ImpactPoints of Impact• Review existing workflows per transaction Review existing workflows per transaction
– Can workflow be improved/automated?Can workflow be improved/automated?
– Can information returned be better utilized/automated?Can information returned be better utilized/automated?
– Do you use non-standard codes in these processes? Do you use non-standard codes in these processes?
– Is there value in implementing transactions which you do Is there value in implementing transactions which you do not currently conduct electronically?not currently conduct electronically?
– Is there value in implementing transactions not currently Is there value in implementing transactions not currently required by the California DWC?required by the California DWC?
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• Do you need to changes your direct data entry systemsDo you need to changes your direct data entry systems
• Data content (data elements) must meet the data Data content (data elements) must meet the data content portion of the California electronic standardcontent portion of the California electronic standard
• Systems will also need to be capable of receiving data Systems will also need to be capable of receiving data transfers from the DWCtransfers from the DWC
• Coming soon-If provider chooses to send data Coming soon-If provider chooses to send data electronically, payer must acceptelectronically, payer must accept
• Do you have a crosswalk from standard code sets to Do you have a crosswalk from standard code sets to ones used by your internal systems?ones used by your internal systems?
Internal SystemsInternal Systems
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Questions to ask a software vendorQuestions to ask a software vendor• Will your vendor be DWC compliant by the Will your vendor be DWC compliant by the
mandated deadlines?mandated deadlines?
• What are your service level agreements for What are your service level agreements for continued support?continued support?
– New versionsNew versions
– TrainingTraining
• Will the required code sets be submitted?Will the required code sets be submitted?
• How much lead time is required to install and test How much lead time is required to install and test the software?the software?
• What is the minimum hardware requirement for What is the minimum hardware requirement for servers and workstations to run the California servers and workstations to run the California compliant version? compliant version?
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Part V Part V Where are you now?Where are you now?
Assigned a “point person” for your office?Assigned a “point person” for your office?
Completed an Action Plan?Completed an Action Plan?
Work toward completing your Gap Analysis?Work toward completing your Gap Analysis?
Communicated with vendors, billing services, or Communicated with vendors, billing services, or the DWC concerning 3/18/06? the DWC concerning 3/18/06?
Test Internally?Test Internally?
Scheduled External Testing?Scheduled External Testing?
Staying abreast of upcoming requirements?Staying abreast of upcoming requirements?
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WhereWhere are you? are you?Which of the following has gained influence Which of the following has gained influence
over strategic decision making?over strategic decision making?
SignificantSignificantIncreaseIncrease
Slight Slight IncreaseIncrease
NoNoChangeChange
BoardsBoards 60%60% 33%33% 7%7%
InvestorsInvestors 44%44% 42%42% 14%14%
GovernmentGovernment 34%34% 46%46% 20%20%
Rating AgenciesRating Agencies 26%26% 49%49% 25%25%
RegulatorsRegulators 57%57% 34%34% 9%9%
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Where are you?Where are you?What Investment in new governance-related activities What Investment in new governance-related activities
will you make in the coming year?will you make in the coming year?
Decrease InvestmentDecrease Investment 1%1%
No change in InvestmentNo change in Investment 25%25%
0-5% increase0-5% increase 30%30%
5-10% increase5-10% increase 25%25%
10-15% increase10-15% increase 9%9%
15-25% increase15-25% increase 5%5%
More then 25% increaseMore then 25% increase 5%5%
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Where are you?Where are you?What governance-related business activities will you What governance-related business activities will you
increase investment in the coming year?increase investment in the coming year?
The Compliance functionThe Compliance function 64%64%
IT SpendingIT Spending 38%38%
Internal communicationsInternal communications 26%26%
Instilling a culture of compliance Instilling a culture of compliance though out the organizationthough out the organization
42%42%
Interaction with key stakeholders Interaction with key stakeholders (regulators, government, lobby groups)(regulators, government, lobby groups) 31%31%
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DWC\WCIS HelpDWC\WCIS Help
• WCIS web site (www.dir.ca.gov)WCIS web site (www.dir.ca.gov)
• WCIS Trading Partner LiaisonsWCIS Trading Partner Liaisons
• WCIS e-mail ([email protected])WCIS e-mail ([email protected])
• WCIS Medical EDI TrainingWCIS Medical EDI Training
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WCIS Trading Partner LiaisonsWCIS Trading Partner Liaisons
Damon ChenDamon [email protected]@dir.ca.gov
Johnny LeeJohnny [email protected]@dir.ca.gov
Elisema CantuElisema [email protected]@dir.ca.gov
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WCIS Medical EDI Training WCIS Medical EDI Training
• Training Conference in Los Angels AreaTraining Conference in Los Angels Area
• Training Conference in Oakland AreaTraining Conference in Oakland Area
• Web Based step by step trainingWeb Based step by step training
• Help Desk by telephone or emailHelp Desk by telephone or email