WEDI paper seeks to offer guidance on remittance advice

The use of third-party business associates has complicated the resolution of claims communications with providers; standards, communication can help.

WEDI paper aims to assist communication between payers, providers and business associates.

A white paper from WEDI aims to sort out best practices in managing payments and settling accounts between providers and payers when a payer uses a business associate that processes and pays claims on behalf of a payer.

The document, from WEDI’s advice and payment subgroup, seeks to provide guidance to suggest approaches to use electronic standards in the process, rather than resorting to manual processes and complicated communications between multiple entities trying to adjudicate the payment.

These complications arise when health plans subcontract some or all claims services to a business associate, such as a another health plan or vendor. While the patient pays an in-network amount for 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 advice from an entity that they did not submit the claim to and may receive the payment in a form other than their enrolled payment method,” the white paper notes.

The paper, accessible here, discusses the challenges related to remittance advice information for these situations. While it addresses issues related to in-network providers, the challenges may apply to out-of-network providers as well.

Best practices include the use of standards, particularly for electronic remittance advice (ERA) and electronic funds transfer (EFT) to communicate to all entities; transparent communication; and responsibilities of the health plan to mediate the communication of critical information.While the paper discusses challenges related to remittance advice in these situations, challenges related to the payment of these claims “may be addressed in a future version of the Electronic Payments Guiding Principles paper, which will be available at WEDI’s website.

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