XIFIN Complaint to CMS Results in Modified Guidance on Health Plans’ Payment of Claims
Customer advocacy is a core tenet of our business at XIFIN. While it’s easy for companies to say that customer-centricity and advocacy are core values, the proof is whether customers experience the value and impact of said commitment. The following article, reprinted from the XIFIN XiConnect Customer Newsletter Issue #3 2022, highlights a recent success that positively impacts numerous XIFIN clients.
Based on customer feedback and concerns about transaction fees charged to non-covered entities by some third-party payment processors, XIFIN filed a complaint with CMS in January 2022 on behalf of our customers. In working with our customers, it was clear that some third-party payment processors contracted by health plans to pay claims were charging fees for EFT and ERA transactions in the range of 1.9% - 2% of the payment value. At the time of the complaint, more than 200 health plans were using one of these third-party payment processors. Many of these processors were also issuing one-time use virtual credit cards that apply credit card processing fees for redemption. As a result, providers were not receiving full reimbursement for their services provided; these fees added up quickly.
The good news is that CMS acted swiftly based on our complaint. In March 2022, CMS issued guidance to clarify requirements in conducting electronic transactions using the EFT and ERA standards. The guidance addresses two important items related to the complaint:
Providers can request that a health plan pay claims using the EFT and ERA transaction standards, and when they do so, the health plan must comply.
According to the clarified guidance, “Compliance with a provider’s request to use the adopted standards for the EFT and ERA transmissions includes the health plan sending Stage 1 payment initiation transmissions that authorize the health plan’s financial institution to transmit payment through the ACH network directly to the provider’s financial institution and sending ERA transactions directly to the provider or the provider’s business associate.”
A health plan cannot require or force a provider into a third-party vendor contract as a condition of receiving ERA/EFTs.
“While it may be necessary for a provider to work with a business associate that operates on behalf of a health plan, a health plan may not require that a provider agree to receive payment or reassociation services from its business associate (nor may the business associate otherwise require this) as a condition of receiving health care payments using the adopted EFT and ERA standards.”
Finally, the clarified guidance advises that “Providers should be aware of any agreements they have in place with each of the health plans they work with related to claims payment terms. If after submitting a request to a health plan to conduct health care EFT and ERA transactions using the adopted standards, a provider believes the health plan has failed to use or comply with any of the adopted standards or operating rules, the provider may file a complaint against the health plan with the CMS NSG through the Administrative Simplification Enforcement Testing Tool (ASETT).”
You can read the entire guidance letter here.
The XIFIN team is thrilled with the responsiveness of CMS regarding this issue, and it is a testament to the value of our customer advocacy focus. Working on behalf of our entire client population often provides the additional leverage required to make important changes happen. We remain committed to continuing to advocate on our clients’ behalf, whenever warranted.
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