EDI Services Restoration Update – March 6, 2024

EDI Services Restoration Update - March 6, 2024

To Every Unlimited Systems Client Leader:

The several days since our March 1 update have seen encouraging signs of progress in the effort to restore EDI Services. Unlimited Systems is concurrently pursuing several parallel initiatives to deliver your electronic claims to the broadest possible set of payers:

Maximizing commercial claim throughput for all customers via Availity’s temporary ‘Lifeline’ service option.
Submitting Medicare claims directly to the submission portals offered by a subset of the Medicare Administrative Contractors (MACs).
Activating the Zenith EDI Switch to connect g4-Centricity and Unlimited Financials directly to the Availity Gateway at scale on an automated basis and with a pathway to governmental payers, including Medicare.
Preparing to test Optum’s ‘Intelligent EDI’ clearinghouse, ‘IEDI’, that is being implemented to substitute, at least temporarily, for Change Healthcare.

Your engagement with our support teams remains a source of inspiration and renewing initiative. We continue to maintain focus on the full restoration of EDI Services as rapidly as possible. Our efforts, and your opportunity to engage with and take advantage of them, is described further below:

Availity Lifeline Services
The backlog of claims accrued since Wednesday, February 21st because of the Change Healthcare cyberattack included a meaningful portion that were qualified for delivery to select commercial payers via Availity’s temporary ‘Lifeline’ portal. Clearing that backlog began last Friday and was managed throughout the weekend.

530,000 claims totaling $1.23 billion in specialty healthcare charges have been submitted via the Lifeline mechanism. We have also received over 350,000 gateway and payer reports, which we are classifying and transforming into a format that can be processed back into your practice management system. Our aim is to have those responses flowing through to your Unlimited Financials or g4-Centricity database by the end of this week. We are also maintaining a continuously supervised connection to the Availity Lifeline for newly qualifying claims while we work to implement an automated, scalable connection to the Availity Gateway whose features will exceed the legacy Change Healthcare solution. Your Unlimited Systems Claims Advocate can provide practice-specific advice about Lifeline claim volume.
MAC Direct Submission
There are seven regionally based Medicare Administrative Contractors (MACs) who process claims on behalf of CMS. Four of them serving thirty-three states (FCSO, Noridian, Novitas and WPS) offer bulk upload options for claim submission. Palmetto, NGS, and CGS do not offer this mechanism. Based on our team’s active efforts with multiple customers to explore MAC portal submission, these mechanisms are technically complex, labor intensive and constrained to single practice at a time. They are not sustainable long-term, but theoretically offer an interim way around the Gateway layer while waiting for EDI Enrollment to complete. Unlimited Systems is pursuing engagement at the leadership level with the MACs to determine whether/how we can intervene at scale on behalf of multiple clients. We are finding that submission enrollment timeframes and testing criteria vary by MAC. The bottom line is that the MAC pathway warrants attention but is unlikely to be a large-scale problem solver absent breakthroughs we are still pursuing.
EDI Switch/Availity Gateway
Since completing the formal network enrollment process with Availity last Friday, we have remained actively engaged with their resources to prepare for activation of a full-service connection to their Gateway. The Availity pathway will ultimately include access to the Essentials Pro EDI portal which can be used to track claim and remittance activity. Automatically directing your claims to Availity and utilizing Availity Gateway services and payer connections requires configuration of your account at our new Zenith EDI Switch (www.zenithswitch.app).

Starting Thursday, March 7th every customer who has returned an EDI Switch Authorization will be furnished credentials and instructions to active your Switch account. Our Claims Advocates will reach out directly to the contact(s) you identified to support the activation step. If you need an EDI Switch Authorization Form so that your practice can be connected with the Availity Gateway, please contact our Consulting Desk (support@unlimitedsystems.com; 513-821-3012) or your Claim Advocate directly.

We are prepared to initiate payer-specific EDI enrollment via the Availity Gateway toolset as soon as that resource is available to us. Due to the high volume of new customers turning to Availity, gaining access to that feature is taking longer than we would like. We are actively working on several fronts to escalate the priority of this customer cohort and appreciate the advice and influence that several of our major customers have been able to contribute to this effort. Even prior to the enrollment process, we will leverage the broader payer catalog of the full Availity Gateway and Essential Pro tools for your benefit.
Optum IEDI
Since Friday, March 1st Optum has been shifting focus to customers who used the ‘Change Medical Network’ for EDI Services before it went offline. Optum’s goal is to repurpose their ‘Intelligent EDI’ clearinghouse, aka ‘IEDI’, to provide connections to commercial payers. IEDI was previously an internal service that was unaffected by the ransomware intrusion. Optum’s first goal is to quickly stand up a version of ‘Lifeline’ services. However, they report being in substantial discussions with payers, including CMS and the MACs, to permit IEDI to effectively operate as Change Healthcare. Were that achieved, IEDI could be a temporary pathway to submit Medicare claims without re-enrollment that would be much more scalable than individual practice submissions to regional MACs. Because of the substantial nature of our customer base, Unlimited Systems was one of two organizations selected by Optum to fast track through the testing process. We are actively engaged with Optum and anticipate being able to provide a progress report in less than one week.

Unlimited’s emphasis on parallel paths, and the infrastructure investment in the Zenith EDI Switch are indicative of a ‘new normal’. While our current focus is launching a broad Availity Gateway solution, we are actively investing in resilience, multiple route options, and enhanced tools to respond in the event of any future EDI service disruption.

Some other relevant topics for this update include:

Paper Claim Submission
The question of whether to encourage paper claim submission remains an active subject of discussion at Unlimited Systems and with our customers. While we appreciate the natural desire to act in the absence of electronic pathways, it is important to understand the downstream consequences of introducing paper claims. Inherently:

The complex nature of specialty healthcare claims, including the heavy use of line-item modifiers, extended lists of qualifying diagnoses codes, and therapy-specific authorization numbers creates significant risk to accurate entry of paper claims into payer systems.
To the extent these risks result in escalation of claim denials and underpayments by the time a payer processes a paper claim batch, a disproportionate volume of AR will result. As electronic environments are restored at scale and attention reverts to typical business office processes, it will be difficult to achieve target collection rates for claims submitted on paper. If that happens, the practice will experience a permanent cash deficit, rather than a transient delay.

With those considerations in mind, our Claims Advocates understand that every customer situation is different. While there is no one-size fits all alternative, practices may consider the following options:

Paper Claim Submission (consider for low dollar claims): HHS advises that "the MAC's must accept paper submissions if a provider needs to file claims in that method." Given this guidance, it is an option to print and submit paper claims after contacting your MAC to confirm readiness to receive.
Manual Claim Posting (consider for high dollar claims): By logging into your MAC portal individual claims can be hand keyed and submitted.

Optum Working Capital Loans
In addition to their effort to restore the Change Healthcare environment and expand the IEDI platform, Optum is also promoting short-term zero interest loans to practices impacted by the cyberattack on their systems. The full mechanics of this Working Capital program are still being defined, some information is available at https://www.optum.com/en/lp/workingcapital.com.html.

Unlimited Systems will continue to bring forward updates about this program as it is clarified.

Industry Stakeholder Engagement
Unlimited Systems has maintained calls through the week with both COA’s representative and multiple GPO leaders. We are actively strategizing with COA how to move forward from their initial success prompting CMS to issue guidance to the MACs regarding expedited provider enrollment. We remain impressed with the GPO’s desire to support customers, which we understand they are reviewing with you on a case-by-case basis.

Two weeks into an unprecedented EDI Services disruption feels like forever. It can be hard to see progress day-to-day, particularly for customer teams who are not directly engaged in the standup and testing of alternative submission paths. However, underlying progress towards restoration has been significant over the past several days. The collective effort with you to respond faster than other industry participants is keeping us at the front of the line and highly visible. Customers of Unlimited Systems who continue to provide patient care and generate claims can ultimately expect to see full reimbursement for those services. In addition to activating new EDI pathways, we are carefully tracing and accruing all claim activity so that none of your claims/invoices for patient care services are lost during this disruption.